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OPrOilETRr  LIB. 


DISEASES  OF  THE  EYE 

A  HANDBOOK  OF  OPHTH.\LMIC  PRACTICE 
FOR      STUDENTS      AND      PRACTITIONERS 


BY 
GEORGE  E.  DE  SCHWEIXITZ,  AI.D.,  LL.D.  (Univ.  of  Pa.) 

Professor  of  Ophthalmology  in  the  University  of  Pennsylvania;  Ophthalmic  Surgeon 

to  the  University  Hospital;  Consulting  Ophthalmic  Surgeon  to  the 

Philadelphia  General  Hospital  and  the  Orthopedic 

Hospital  and  Infirmary  for  Xervous  Diseases; 

Colonel.  M.  R.  C,  U.  S.  Army 


NINTH  EDITION,  RESET, 
WITH  41  s  ILLUSTRATIONS 
AND    7    COLORED    PLATES 


PHILADELPHIA  AND  LONDON 

W.  B.  SAUNDERS  COMPANY 

1921 


OPTOMETRI  lib; 


Copyright,  i8y2,  by  W.  B.  Saunders.    Reprinted  Januarj'.  1893.  and  August,  1893.    Revised,  reprinted, 
and^ecopyrighted  May,  1896.    Reprinted  August,  1897.    Revised,  reprinted,  aijd  recopyrighted 
January,    1899.    Revised,    entirely   reset,    electrotyped,  reprinted,  and    recopyrighted 
October,  1902.    Revised,  reprinted,  and  recopyrighted  January,  1906.    Revised, 
reprinted,  and  recopyrighted  April,   1910.    Revised,  reprinted,  and  re- 
copyrighted May,  I9i3-    Reprinted  April,  1915.    Revised,  entirely 
reset,  reprinted,  and  recopyrighted  May,  1916.    Reprinted 
November,  1917.    Revised,  entirely  reset,  reprinted, 
and  recopyrighted  July,  192 1. 

Copyright,  1921,  by  W.  B.  Saunders  Company. 


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^M     NieU       N    AMCRiCA 


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PREFACE  TO  THE  NINTH  EDITION 


In  the  Ninth  Edition  of  this  textbook,  as  heretofore,  the  revision 
includes  reference  to  important  ophthahnic  observations,  therapeutic 
measures  and  surgical  procedures  which  have  been  made,  recom- 
mended and  devised  during  the  last  four  years. 

The  World  War  has  furnished  unusual  opportunities  and  given 
rise  to  an  extensive  literature  in  these  regards,  which  have  been 
utilized  within  the  marked  limitations  that  a  book  of  this  character 
entails.  But  for  a  thorough  study  of  ophthalmic  problems  as  they 
present  themselves  during  warfare,  the  student  and  practitioner  must 
turn  to  the  many  special  books,  monographs  and  journal  articles 
which  are  now  available. 

Reference  to  the  following  subjects  appears  for  the  first  time: 
Jennings'  SeK-Recording  Test  for  Color  Blindness  and  Nagel's  Card 
Test;  Ophthalmoscopy  with  Red-Free  Light;  Measurement  of  Accom- 
modation by  Skiascopy;  Electric  Desiccation  in  the  Treatment  of  Lid- 
Carcinomas  and  Epibulbar  Growths;  Unusual  Forms  of  Conjunctivitis; 
Poisonous  Gas  Conjunctivitis;  Striate  Clearing  of  Corneal  Opacities; 
Trypanosome  Keratitis;  Superficial  Linear  Keratitis;  Keratitis 
Pustuliformis  Profunda;  Primary,  Progressive  Calcareous  Degenera- 
tion of  the  Cornea;  Anterior  Lenticonus;  Cysticercus  of  the  Vitreous 
(previously  onlj'  mentioned);  Localization  and  Organization  of  the 
Cortical  Centers  of  Vision,  according  to  Holmes  and  Lister;  Contusion 
and  Concussion  of  the  Eyeball  in  Warfare;  Epidermic  Grafts  for  the 
Correction  of  Ectropion  (Epithelial  Overlay);  Free  Dermic  (Whole- 
Skin)  Grafts  for  the  Correction  of  Ectropion  (previously  only  briefly  re- 
corded); Epithelial  Outlay  for  the  Correction  of  Ectropion  (Gillies' 
Operation);  Esser's  Epithelial  Inlay;  Maxwell's  Operation  for  Con- 
tracted Socket;  Conjunctivoplasty;  Modified  Brossage,  Simple  Exci- 
sion of  the  Retrotarsal  Folds,  and  Combined  Excision  of  the  Retro- 
tarsal  Folds  (Heisrath's  Operation)  in  the  Treatment  of  Trachoma; 
Trephining  the  Sclera  for  Detachment  of  the  Retina;  Sclerotomy 
combined  with  Electrol3i;ic  Punctures  for  Detachment  of  the  Retina 
(Verhoejff's  Operation);  Resection  of  the  Sclera  for  Detachrhent  of 
the  Retina  (]Mueller's  Method);  Cartilage  Implantation  After  Enu- 
cleation of  the  Eyeball;  Mosher's  Operation  for  Dacryocystitis. 

In  certain  portions  of  the  book  the  re\'ision  has  included  a  rear- 
rangement, with  additions,  of  the  subject-matter,  for  example,  in  the 
paragraphs  devoted  to  Visual  Field  Examination,  Glaucoma,  Sym- 
pathetic Ophthalmia,  and  Blepharoplasty.     More  frequentlj^  than  in 

7 


iM758C66 


8  PREFACE    TO    THE    NINTH    EDITION 

* 

previous  editions,  foot-note  references  to  important  publications  have 
been   inserted.     A   number  of   new   illustrations   have   been   added. 

The  author  is  indebted,  as  in  former  editions,  to  Lt.  Col.  Elliot  for 
the  description  of  Cornco-Scleral  Trephining;  to  Dr.  William  M. 
Sweet  for  an  account  of  his  method  of  localizing;  foreign  bodies  in 
the  eyeball  by  means  of  the  X-ray;  to  Dr.  Edward  Jackson  for  the 
Section  devoted  to  Skiascopy,  or  the  Shadow  Test;  and  to  Dr.  Alex- 
ander Duane  for  certain  excellent  suggestions  which  have  been  incor- 
porated in  the  Chapter  on  the  Movements  of  the  Eyeballs  and  Their 
Anomalies. 

The  author  trusts  that  this  revision  and  these  additions  may 
prove  to  be  satisfactory.  Again  he  expresses  his  high  appreciation  of 
the  cordial  reception  which  has  thus  far  been  accorded  to  this  book. 

O.  E.   i)K  S. 
1705  Walnut  Stkkkt, 

Philadelphia,  Pa. 
July,   1921. 


CONTENTS 


CHAPTER  I 

Page 

General  Optical  Principles 17 

Transmission  of  Light,  17 — Refraction,  17 — Index  of  Refraction,  17 — 
Prisms,  18 — Refraction  through  a  Prism,  18 — Angle  of  Deviation,  19 — 
Numbering  Prisms,  19 — Dennett's  Method,  19 — Prentice's  Method,  20 — 
Rays  of  Light,  21 — Lenses,  23 — Foci  of  Convex  Lenses,  23 — Foci  of 
Concave  Lenses,  25 — Formation  of  Images  by  Lenses,  25 — Focal  Distance 
of  a  Lens,  28 — Numeration  of  Lenses,  28 — The  Diopter,  29 — Spheric 
Lenses,  30 — Cylindric  Lenses,  30 — Toric  Lenses,  30— Combination  of 
Lenses,  31 — Visual  Angle,  34 — Visual  Acuteness,  35 — Limit  of  Perception, 
35 — Normal  Acuteness  of  Vision,  35 — Accommodation,  35 — Angle 
Gamma,  41 — Angle  Alpha,  41 — Convergence,  43 — Meter  Angle,  45. 

CHAPTER  II 

Examination  op  the  Patient  and  External  Examination  of  the  Eye — 

Functional  Testing 47 

Direct  Inspection  of  the  Eye,  47 — Blood-vessels  of  the  Conjunctiva,  48 — 
Temperature  of  Conjunctiva,  50 — Inspection  of  the  Cornea,  50 — Diameter 
of  Cornea,  51 — Sensibility  of  Cornea,  51 — ObUque  Illumination,  51 — The 
Corneal  Loupe,  52 — Corneal  Microscope,  52 — The  Color  of  the  Iris,  52 — 
The  Pupil,  53 — Measurement  of  the  Pupil,  54 — Mobility  of  the  Iris,  55 — 
Pupil-reflexes,  55 — Innervation  of  the  Iris  and  Explanation  of  the  Pupil- 
reflexes,  57 — Dilatation  of  the  Pupil,  61 — Contraction  of  the  Pupil,  62 — 
Convergence  Anomalies  of  the  Pupils,  64 — Unequal  Pupils,  65 — Special 
and  Paradoxic  Pupillary  Phenomena,  65 — Testing  Acuteness  of  Vision, 
66- — Light-sense,  67 — Color-sense,  69 — Method  of  Holmgren,  69 — Method 
of  Thomson,  70 — Lantern-test,  70 — Pseudo-isochromatic  Plates  of  Still- 
ing, 71 — Special  Tests,  72 — -Accommodation,  72 — Mobility  of  the  Eyes, 
73 — Balance  of  the  External  Eye  Muscles,  73 — Orthophoria,  74 — Hetero- 
phoria,  74 — Heterotropia,  74 — Esophoria,  74— Exophoria,  74 — Hyper- 
phoria, 74 — Cyclophoria,  74 — The  Screen  (Cover)  and  Parallax  Tests, 
74 — Prism  Tests,  75 — Equilibrium  Test,  75 — Obtuse-angled  Prism  Test, 
78 — Insufficiency  of  the  Obhque  Muscles  (Cyclophoria),  78 — Cobalt  Test, 
79— The  Rod  Test,  79— Amphtude  Convergence,  80— Field  of  Vision, 
81 — Binocular  Field  of  Vision,  86 — Abnormalities  of  Visual  Field  and 
Scotomas,  88 — Tension,  90 — Proptosis,  Exophthalmos,  92 — Position  of 
the  Eyes,  92 — Counterfeited  Blindness,  92. 

CHAPTER  III 

Reflection.     The  Ophthalmoscope  and  its  Theory.     Ophthalmoscopy 

AND  Skiascopy 93 

Reflection,  93 — The  Ophthalmoscope,  95 — Direct  Method,  97 — Size  of 
the  Image,  99 — Indirect  Method,  99 — Size  of  the  Image,  100 — Oph- 
thalmoscopy, 101 — Direct  Method  of  Ophthalmoscopy,  101 — Exami- 
nation of  the  CQrnea,  Anterior  Chamber  and  Lens  by  Transmitted  Light, 
103 — Examination  of  the  Vitreous,  103 — Location  of  Opacities  in  the 
Transparent    Media,    103 — The  Optic  Nerve,   104 — The  Blood-vessels, 

9 


10  CONTENTS 

Paoe 
105— PhysioloRic  Variations,  106— The  Retina,  108— Macula  Lutea,  108 
—The  Choroid.  110 — Ophthalmoscopy  with  Red-free  Light,  111— Deter- 
mination of  Refraction  by  the  Ophthalmoscope,  111 — Ophthalmos- 
copy by  the  Indirect  Method,  114 — (Jphthalmodiaphanoscopy,  115 — 
Ophthalmometry,  116 — Optometry,  116^Skiascopy.  117 — Measurement 
of  Accommodation  by  Skiascopy,  122 — The  Concave  Mirror,  123 — 
Cycloplegics  and  Mydriatics,  123. 

CHAPTKR  IV 

Normal  and  .\bnormal  Refraction 126 

Emmetropia,  126 — Ametropia,  127 — Hyperopia,  127 — Determination 
and  Correction  of  Hyjjeropia,  129 — Ordering  of  Glas.ses,  132 — Myopia, 
133 — Determination  and  Correction  of  Myopia,  140 — Treatment  of 
Myopia,  141 — Ordering  of  Glasses,  143 — Astigmatism,  145 — Seat  of 
Astigmatism,  146 — Regular  .\stigmatism,  150 — Recognition  of  Astigma- 
tism, 151 — Correction  of  Astigmatism,  152 — Ordering  of  Classes,  155 — 
Irregular  Astigmatism,  156 — Surgical  Treatment  of  Astigmatism,  156 — 
Anisometropia,  156 — Presbyopia,  157 — Correction  of  Presbyopia,  157 — 
Distortion  of  Objects  by  Cylindric  Lenses,  162 — Bifocal  Lenses,  163 — 
Spectacles  and  their  Adjustment,  163. 

CHAPTER  V 

Diseases  of  the  Eyelids 167 

Congenital  Anomalies,  167 — Edema  of  the  Lids,  169 — Erythema  of  Lids, 
169 — Urticaria,  170 — Erysipelas,  170 — Abscess  of  the  Lid,  170 — Furuncle 
of  the  Lid,  170 — Blastomycosis  of  the  Eyehd,  171 — Hordeolum,  171 — 
Exiintiicinatous  Eruptions,  172 — Eczema  of  the  Lids,  172 — Herpes  Zoster 
Oi)hthalmicus,  173 — Herpes  FaciaUs  of  the  Lids,  174 — Blepharitis,  174 — 
Phthiriasis,  178— Sporotrichosis  of  the  Lids,  178— Syphilis  of  the  Lids,  178 
— Tumors  and  Hypertrophies,  179 — Xanthelasma,  181 — Chalazion, 
182 — Sarcoma,  183 — Lymphomas,  183 — Carcinoma,  1S3 — Lupus 
Vulgaris,  187 — -Lepra,  187 — Xeroderma  Pigmentosum,  188 — Elephantia- 
sis Arabum,  188— Tarsitis,  188- Belpharospasm,  189— Ptosis,  190— 
Belpharochalasis,  190 — Lagophthalmos,  191 — Symblepharon,  191 — Anky- 
loblepharon, 192 — Blepharophimosis,  192 — Trichiasis  and  Distichiasis, 
192— Alopecia  of  the  Eyelids,  193— Entropion.  193— Ectropion,  194— 
Seborrhea,  195 — Milium,  195 — MoUuscum  Contagiosum,  195 — Ephi- 
drosis,  196 — Chroinidrosis,  196 — Sebaceous  Cysts,  196^Injuries,  196. 

CHAPTER  VI 

Diseases  OK  THE  Conjunctiva 199 

Congenital  .Anomalies,  199 — Hyperemia,  199 — Conjunctivitis  (Oi)lithal- 
mia),  200^SimpIe  or  Catarrhal  Conjunctivitis,  201— .Vcute  Contagimjs 
Conjunctivitis,  202  — Pneumococcus  Conjunctivitis,  203  —Influenza 
Bacillus  Conjuiu-tivitis,  204 — S\vimming-l)ath  Conjunctivitis,  204 — 
Diplol)acillus  Conjunctivitis,  204 — Catarrhal  Epidemic  (\)njuuctivitis, 
207-  Ivxanthematous  Conjunctivitis,  207  -Purulent  Conj>mctivitis, 
20S — Conjimctivitis  Neonatorum,  20S  -Inclusion-l)leimi)rrhea  of  New- 
born, 216  -Purulent  Conjunctivitis  i[\  Young  (iirls,  216 — Conorrhcal 
Conjunctivitis,  217 — Metastatic  Gonorrheal  Conjimctivitis,  220 — 
Non-specific  Purulent  Conjunctivitis,  221 — (^roupous  Conjunctivitis, 
221 — l)iphlheritic  Conjunctivitis,  2'2',\ — Phlyctenular  Conjunctivitis, 
224 — Vernal  Conjunctivitis,  225  —Follicular  Conjunctivitis,  22S — • 
Tracliomatous  Conjunctivitis  (Tradiomal,  229 — Sequels  and  Conipli- 
cutioiiH   of   Trachoma,    236 — Parinaud's   Conjunctivitis,    241 — Sporotri- 


CONTENTS  1 1 

Page 
chosis  of  Conjunctiva,  242 — Chronic  Conjunctivitis,  242 — Egj-ptian  and 
Militan-  Conjunctivitis,  243 — Lacrimal  Conjunctivitis,  243 — ^Lithiasis 
Conjunctivae,  244 — Toxic  Conjunctivitis,  244 — Atropin  Conjunctivitis, 
244— Traumatic  Conjunctivitis,  244 — Poisonous  Gas  Conjunctivitis, 
245 — Conjunctivitis  Nodosa,  246 — Xerophthalmos,  247 — Amyloid 
Disease  of  the  Conjunctiva,  248 — Conjunctivitis  Petrificans,  248 — 
Pter3-gium,  248 — Pinguecula,  249 — Abscess  of  the  Conjunctiva,  249 — 
Ecchymosis  of  the  Conjunctiva,  249 — Chemosis,  250 — Emphysema,  250 
— Lymphangiectasis,  250 — Syphilis,  250 — Tumors  and  Cysts,  250 — 
Lepra,  254 — Lupus,  254 — Tubercle,  255 — Pemphigus,  256 — Injuries, 
256 — Affections  of  the  Caruncle,  257 — Argyria  Conjunctivae,  258. 

CHAPTER  VII 

Diseases  of  the  Corxea 259 

Keratitis,  259 — Phlyctenular  Keratitis,  259 — Ulcers  of  the  Cornea,  263 — 
Results  of  Corneal  Ulceration,  278 — Staphyloma,  278 — Keratomalacia, 
282 — Neuroparalytic  Keratitis,  283 — Keratitis  E  Lagophthalmo,  284 — 
Herpetic  Keratitis,  285 — Rosacea  Keratitis,  286 — Keratitis  Bullosa,  286 
— Vascular  Keratitis,  287 — Parenchymatous  Keratitis,  287 — Keratitis 
Punctata  Syphihtica,  294 — Keratitis  Punctata,  294 — Keratitis  Profunda, 
295 — Keratitis  Superficialis  Punctata,  295 — Superficial  Linear  Keratitis, 
296 — Keratitis  Marginalis  Profunda,  297 — Keratitis  Pustuliformis 
Profunda,  297— Keratitis  Disciformis,  297— Grill-Uke  Keratitis,  298— 
Marginal  Degeneration  of  the  Cornea,  299 — Primary  Progressive, 
Calcareous  Degeneration  of  the  Cornea,  299 — Epithelial  Dystrophy  of 
the  Cornea,  300 — Filamentous  Keratitis,  300 — Riband-like  Keratitis, 
300 — Blood-staining  of  the  Cornea,  301 — .Arcus  Senihs,  301 — Conical 
Cornea,  302 — Injuries,  303 — Traumatic  Keratitis,  303 — Foreign  Bodies, 
303 — Relapsing  Traumatic  Keratitis  Bullosa,  305 — Wounds,  305 — Burns 
and  Scalds,  306 — Peripheral  Annular  Infiltration  of  the  Cornea,  306 — 
Traumatic  Striped  Keratitis,  307 — Obstetric  Injuries,  307 — Tumors  and 
Cj'sts,  307 — Congenital  AnomaUes,  309. 


CHAPTER  VIII 

Diseases  of  the  Sclera 311 

Episcleritis,  311 — Fugacious  Periodic  Episcleritis,  312 — Scleritis,  312 — 
Sclerokerato-iritis,  314 — Annular  Scleritis,  315 — Posterior  Scleritis,  315 — 
Staphyloma,  315 — Abscess  and  Ulcers,  316 — Tumors,  316 — Injuries,  316 
— Foreign  Bodies,  318 — Congenital  Pigmentation,  322 — Blue  Sclerotics, 
323. 

CHAPTER  IX 

Diseases  of  the  Iris 324 

Congenital  Anomalies,  324 — Hyperemia,  326 — Iritis,  326 — Types  of 
Iritis,  331 — Syphihtic  Iritis,  332 — Rheumatic  Iritis,  336 — Gouty  Iritis, 
337 — Diabetic  Iritis,  338 — Gonorrheal  Iritis,  339 — Iritis  Secondary  to 
Mucous  Membrane  and  Focal  Infection,  340 — Tuberculous  Iritis,  340 — 
Scrofulous  Iritis,  341 — Infectious  Disease  Iritis,  341 — Traumatic  Iritis, 
341 — Sj-mpathetic  Iritis,  342 — Secondary-  Iritis,  342 — Serous  Iritis, 
342— Chronic  Iritis,  342— Operations  for  Iritis,  342— Tumors,  344— 
Sarcoma,  344 — Injuries,  345 — Foreign  Bodies,  345 — Iridodialysis,  345 — 
Rupture  of  the  Sphincter,  346 — Displacement  of  the  Iris,  346 — .AnomaUes 
of  the  Anterior  Chamber,  346. 


12  CONTENTS 

Page 

CHAPTER  X 

DiSEABES    OF    THE    CiLIARV    BoDY    AND    SYMPATHETIC    IRRITATION    AND  INF- 
LAMMATION     348 

Cyclitis  and  Iridocyclitis,  34S— Plastic  Cyclitis,  348— Purulent  Cyclitis, 
349 — I'voitis  or  Serous  Cyclitis,  349 — Injuries  of  the  Ciliary  Body,  356 — 
Syphilis  of  the  Ciliary  Body^3')6 — Tumors  of  the  Ciliary  Body,  357 — 
Syinjjathetic  Irritation,  358 — Sympathetic  Inflammation  (Ophthalmitis), 
359. 

CHAPTKR  XI 

Diseases  of  the  Chokoid 370 

Congenital  Anomalies,  370 — Hyperemia,  371 — Choroiditis,  372 — Super- 
ficial, 374 — Deep,  375 — Diffuse  Exudative  Choroiditis,  375 — Dissemi- 
nated, 376 — Circumscribed  Plastic,  377 — Anterior.  378— Central.  380 — 
Unclassified  forms  of  Choroiditis,  383 — Myopic,  384 — Suppurative 
Choroiditis  and  Iridochoroiditis,  385 — Panophthalmitis,  386 — Tumors, 
388— Sarcoma,  388— Carcinoma,  392— Tuhenlc.  393— Injuries,  394— 
Foreign  Bodies,  394 — Rvipture,  395 — Hemorrhage.  395 — Detachment, 
395— Ossification,  396— Atrophy  of  the  Eyel)all,  39r»— Hypotony.  396— 
Ophthalmomalacia  (Essential  Phthisis  Bulbi),  396. 

CHAPTER  XII 

Glaucoma 397 

Varieties  of  Glaucoma,  397 — Acute  Glaucoma,  406 — Subacute  Glaucoma, 
407— Chronic  Glaucoma,  408 — Treatment,  418 — Secondary  Glaucoma, 
424 — Hemorrhagic  Glaucoma,  424 — Complicated  Glaucoma,  425 — 
Hydrophthalmos,  426. 

CHAPTER  XIII 

Diseases  of  THE  Crystalline  Lens 427 

Congenital  Anomalies,  427 — Coloboma,  427 — Lenticonus,  427 — Cataract, 
427 — Varieties  of  Cataract,  428 — Senile  Cataract,  436 — Juvenile  Cata- 
ract, 436 — Congenital  Cataract,  43() — Complicated  or  Secondary  Cata- 
ract, 440 — Traumatic  Cataract,  441 — .\fter-cataract,  441 — Capsular 
Cataract,  442 — Capsulolenticular  Cataract,  442 — .\rtificial  Ripening, 
445 — Treatment  of  Immature  Cataract,  445 — Treatment  of  Mature  and 
Complete  Cataract,  446 — Treatment  of  Partial  Congenital  Cataract, 
446 — Dislocation  of  the  Crystalline  Lens,  448 — Foreign  Bodies  in  the 
Ivens,  450. 

('1!AI»T1:R   XIV 

Diseases  of  the  Vitukois 451 

Pus  in  Vitreous,  451 — ()|)acities,  452 — Musca-  N'olitantes.  454  —  Hemor- 
rhage, 455 — Synchysis,  45{) — Synchysis  Scintillaris,  456 — Blood-vessel 
Formation,  457 — Foreign  Bodies,  457 — Entozoa.  458 — DetnchmeMt , 
459— Persistent  lly.doid  Artery,  459. 

(•|i\rii:i{  W 

Diseases  ok  thk  Rktina   .    .  460 

Hyperemia,  460 — ^.Vnemia,  461 — Hyperesthesia,  461 — Anesthesia.  462 — 
Cyan(»sis,  463  I{elinitis,  \{\\ — Types  of  H«'(initis,  466 — vSerous,  4(>6 — 
I'Hreiichymatoiis,  4r)6  -.Syphilitii-,  4(>7 — Hereditary  Syphilitic  Choroido- 
retiiiitis,  470  -Metastatic,  471  Hemorrhagic,  472— .\lltuminuric,  473 — 
AllMiiiiinuric    itetinitis    in    Pregnancy,    476 —Diabetic,    47S  -I^'ukemic, 


CONTENTS  13 

Page 
480 — Proliferating,  480 — Tuberculosis  of  Retina,  482 — Circinate,  483 — 
Striated  Retinitis,  483 — Pigmentary  Degeneration,  484— Detachment, 
490 — Hemorrhages,  494 — Changes  in  the  Retinal  Vessels,  497 — Angioid 
Streaks  in  the  Retina,  499 — Exudative  Retinitis,  499 — Aneurysms, 
501 — Angiomatosis  of  Retina,  501 — Obstruction  of  the  Central  Artery  of 
Retina,  including  Embolism  and  Thrombosis,  501 — Thrombosis  of  the 
Central  Vein,  505 — Traumatisms,  506 — Rq^inal  Changes  from  the  Effect 
of  SunUght  and  Electric  Light,  509 — Ghoma,  510 — Subretinal  Cysticercus 
512 — Cysts  of  the  Retina,  512 — Symmetric  Changes  at  the  Macula 
Lutea  in  Infancy,  513 — Family  Cerebral  Degeneration  with  Macular 
Changes,  514 — Senile  Macular  Atrophy  of  the  Retina,  515. 

CHAPTER  XVI 

Diseases  of  the  Optic  Nerve 516 

Congenital  Anomalies,  516 — Hyperemia,  517 — Anemia,  518 — Intra- 
ocular Optic-nerve  Inflammation  and  Edema,  518 — Intra-ocular  Optic 
Neuritis  (Choked  Disk),  518 — Atrophy  of  the  Optic  Nerve,  530 — 
Varieties  of  Optic-nerve  Atrophy,  533 — Consecutive  Atrophy,  533 — 
Retinitic  and  Choroiditic  Atrophy,  533 — Primary  Atrophy,  534 — 
Secondary  Atrophy,  534 — Hereditary  Optic-nerve  Atrophy,  536 — 
Orbital  Optic  Neuritis  (Retrobulbar  Neuritis;  Central  Amblyopia),  537 — 
Injury  of  the  Optic  Nerve,  541 — Tumors,  542 — Hyaline  Bodies  (Drusen) 
in  the  Papilla,  543. 

CHAPTER  XVII 

Amblyopia,  Amaurosis,  and  Disturbances  of  Vision  Without  Ophthalmo- 
scopic Changes 545 

Congenital  Ambtyopia,  545 — Congenital  Amblyopia  for  Colors  (Color- 
blindness), 546 — Congenital  Total  Color-blindness,  548 — Congenital 
Word-blindness,  548 — Reflex  Amblyopia,  549 — Traumatic  Amblyopia, 
549 — Uremic  Amblyopia  or  Amaurosis,  551 — Glycosuric  Amblyopia, 
551 — Malarial  Amblyopia,  552 — Amblyopia  from  Loss  of  Blood,  552 — 
Amblyopia  from  the  Abuse  of  Drugs,  552 — Quinin  Amaurosis,  553 — 
Methyl-alcohol  Blindness  or  Amaurosis,  554 — Arsenic  Amblj^opia, 
555 — Hysteric  Amblyopia,  555 — Pretended  Amblyopia,  557 — Night- 
blindness,  558 — ^Day-blindness,  559 — Snow-blindness,  559 — Erythropsia, 
560 — Micropsia,  560 — Macropsia,  560. 

CHAPTER  XVIII 

Amblyopia  OF  THE  Visual  Field,  Scotomas,  AND  Hemianopsia 561 

Partial  Fugacious  Amaurosis,  561 — Amblyopia  of  the  Visual  Field,  561 — 
Scotomas,  561 — Hemianopsia,  .564 — Visual  Tract,  564 — Varieties  of 
Hemianopsia,  566 — Peculiarities  of  the  Dividing  Line,  568 — Significance 
of  Hemianopsia,  568 — The  Pupil  in  Hemianopsia,  570. 

CHAPTER  XIX 

Movements  of  the  Eyeballs  and  their  Anomalies 572 

Anatomy  and  Physiologic  Action  of  the  Ocular  Muscles,  572 — Rotation  of 
the  Eyeball  Around  the  Visual  Line,  573 — Associated  Movements,  574 — 
Binocular  Vision,  574 — Overcoming  Prisms,  575 — Field  of  Fixation,  575 — 
Strabismus,  Squint,  or  Heterotropia,  576 — Paralysis  of  the  Exterior 
Ocular  Muscles,  580 — Varieties  of  Diplopia,  581 — Paralysis  of  the 
External  Rectus,  581 — Paralysis  of  the  Internal  Rectus,  582 — Paralysis 
of  the  Superior  Rectus,  583 — Paralysis  of  the  Inferior  Oblique,  584 — 
Paralysis  of  the  Inferior  Rectus,  584 — Paralysis  of  the  Superior  Oblique, 


14  CONTENTS 

Page 
585 — Oculomotor  Paralysis,  586 — Method  of  Examination  and  Diagnosis 
of  the  Affected  Eye,  586 — Recurrent  Oculomotor  Paralysis,  590 — 
Congenital  Paralysis,  591 — Retraction  Movements  of  the  Eyeball 
Associated  with  Congenital  Defects  in  the  External  Ocular  Muscles, 
591 — Relative  Frequency  of  Paralysis  of  the  Orbital  Muscles,  592 — 
Ophthalmoplegia,  593 — Associated  Ocular  Paralyses,  594 — Divergence 
Paralvsis,  595-— Convergence  Paralysis,  595 — Paralysis  of  the  Inferior 
Ocular  Muscles,  595 — Concomitant  Squint,  596 — Varieties  of  Con- 
comitant Squint,  596 — Causes  of  Concomitant  Squint,  597 — Single 
Vision  in  Concomitant  Squint,  599 — Measurement  of  Squint,  600 — 
Treatment  of  Concomitant  Squint,  602 — Vertical  Squint,  608 — Results 
of  Operation  in  Convergent  Squint,  608 — Spastic  Strabismus,  609 — 
Abnormal  Balance  of  the  Ocular  Muscles  (Heterophoria),  609 — DifTer-  ' 
ence  between  Heterophoria  and  Heterotropia,  612 — Nystagmus,  616 — 
Monocular  Diplopia,  618. 

CHAPTER  XX 

Diseases  OF  THE  Lacrimal  Apparatus 620 

Dacryo-adenitis,  620 — Hypertrophy  of  the  Lacrimal  Cdand,  620 — 
Atrophy  of  the  Lacrimal  Gland,  620 — Spontaneous  Prolajjse  of  the  Lacri- 
mal Gland,  020 — Traumatic  Dislocation  of  the  Lacrimal  Gland,  621 — 
Fistula  of  the  Lacrimal  Gland,  621 — Syphihs  of  the  Lacrimal  Gland, 
621 — Dacryops,  621 — Tumors  of  the  Lacrimal  Gland,  621 — Mikulicz's 
Disease,  622 — Anomalies  of  the  Puncta  Lacrimaha  and  Canahculi, 
622 — Anomalies  of  the  Lacrimal  Sac  and  Nasal  Duct,  623 — Dacryocysti- 
tis, 623 — Prelacrimal  Sac  Abscess,  623 — Fistula  of  the  Lacrimal  Sac, 
624 — Obstruction  of  the  Nasal  Duct,  624 — Cause  of  Disease  of  the 
Lacrimal  Sac  and  Nasal  Duct,  624 — Cliaracter  of  the  Lacrimal  Secretion 
under  Pathologic  Conditions,  626. 

CHAPTER  XXI 

Diseases  of  the  Orbit 630 

Congenital  Anomalies,  630 — Periostitis,  631 — Caries  and  Necrosis,  632 — 
Cellulitis,  633 — Inflammation  of  the  Oculo-orbital  Fascia,  63.5 — Throm- 
bosis of  the  Cavernous  Sinus,  635 — Tumors  and  Cysts  of  the  Orbit,  636 — 
Pulsating  Exophthalmos,  640 — Exophthalmic  Goiter,  641 — Affections  or 
Diseases  of  the  Sinuses,  643 — Diseases  of  the  Frontal  Sinus,  643 — Diseases 
of  the  Ethmoid,  644 — Diseases  of  the  Sphenoid,  646 — Diseases  of  the 
Antrum,  646 — Injuries,  649 — Dislocation  of  the  Eyeball,  6.50 — Enoph- 
thalmos,  651 — Exophthalmos,  651^Intermittent  Exophtiialmos,  (>51 — 
Contusion  and  Concussion  of  the  Eyeball,  652. 

CTLVPTEl?    XXII 

Operations <>54 

Preparation  of  the  Skin  of  the  Region  of  Operation,  654 — Preparation  of 
the  Instruments,  654 — Dressings,  6.54— Sutures,  655 — General  .Vnes- 
thesia,  65.5 — Local  Anesthesia,  656 — IiiHltration  Anesthesia,  658 — 
Siegrist's  Method  of  Local  Anesthesia,  6.")S — Local  Hemostasia,  659 — 
Operations  vipon  the  Eyelids,  659 — Ei>ilation  of  the  Eyelashes,  659 — 
Removal  of  a  Meiljomian  Cyst,  660 — Operations  for  Ptosis,  660 — 
Tarsorrhaphy,  665 — Caiithoplasty,  666 — Operations  for  Trichiasis. 
666 — <)|KTat.ion  for  Artificial  Lidborder,  667 — Operations  for  Entroi)i(iii, 
668 — Operation  for  Ectropion,  670  — MIcpharoplasty,  674 — Pedunculated 
Flaps,  675 —Operation  of  Skin  Grafting,  670 — Thiersch's  Method  of 
Skin-grafting,   679 — Operations   for   Prosthesis   in   Cases   of   Cicatricial 


CONTENTS  15 

Page 
Orbital  Sockets,  679 — Esser's  Inlay,  680 — Operations  on  the 
Conjunctiva,  681 — Conjunctivoplasty,  681 — Operations  for  Pter>'gium, 
683 — Operations  for  Symblepharon,  684 — Transplantation  of  Mucous 
Membrane,  684 — Operations  for  Trachoma,  685 — Modified  Brossage, 
687 — Simple  Excision  of  the  Retrotarsal  Fold,  687 — Grattage, 
687 — Subconjunctival  Injections,  689 — Operations  on  the  Cornea, 
689 — Paracentesis  Cornese,  689 — Application  of  the  Actual  Cau- 
tery, 690 — Guthrie-Saemisch  Section,  690 — Operations  for  Staphj-loma, 
691 — Tattooing  the  Cornea,  691 — Operations  for  Conical  Cornea,  692 — 
Operations  upon  the  Iris,  692 — Iridectomy,  692 — Iridotomy,  697 — 
Iritoectomy,  697 — V-shaped  Iridotomy,  698 — Division  of  Anterior 
Synechiae,  699 — Operations  upon  the  Sclera,  699 — Sclerotomy,  699 — 
Combined  Iridectomy  and  Sclerectomy,  700— Sclerectomy  with  a  Tre- 
phine, 703 — Sclerocorneal  Trephining,  703 — Iridotasis,  706 — Cyclodialy- 
sis, 707 — Operations  for  Detachment  of  the  Retina,  708 — Enucleation  of 
the  Eyeball,  709 — Insertion  of  Artificial  Eyes,  711 — Evisceration  of  the 
EyebaU,  712 — Mules'  Operation,  713 — Implantation  of  an  Artificial  Globe 
in  Tenon's  Capsule  after  Removal  of  the  EyebaU,  714 — Implantation  of 
Cartilage,  714 — Fat  Implantation  into  Tenon's  Capsule,  715 — Implanta- 
tion of  a  Glass  or  Gold  Ball  into  the  Orbit  after  Remote  Enucleation  of  an 
Eyeball,  715 — Removal  of  Metallic  Foreign  Bodies  from  the  Interior  of 
the  Eye,  716 — Extirpation  of  the  Whole  Contents  of  the  Orbit,  719 — Re- 
moval of  Tumors  and  Cysts  from  the  Orbit,  719 — Resection  of  the  Tem- 
poral Wall  of  the  Orbit,  720 — Operations  for  Cataract,  722 — Needle  Oper- 
ation (Discission),  722 — Suction  Method,  724 — ^Linear  Extraction,  724 
— Extraction  of  Hard  Cataract,  725 — Extraction  without  Iridectomy, 
725 — Extraction  with  Iridectomy,  726 — Extraction  without  Capsu- 
lotomy,  726 — Preparation  of  the  Patient  and  the  Eye,  726 — Position  of 
the  Patient,  728 — Instruments,  Solutions,  and  Dressings,  728 — After- 
treatment,  733 — Accidents  during  Cataract  Extraction,  734 — Smith's 
Operation  for  Extraction  of  Cataract,  735 — AnomaUes  in  the  Healing 
Process,  738 — Choice  of  an  Operation,  744 — Preliminary  Iridectomy, 
744 — Operations  for  After-cataract  (Secondary  Cataract"),  745 — Oper- 
ations upon  the  Eye  Muscles,  747 — Complete  Tenotomy,  747 — Tenotomy 
of  the  Inferior  Oblique,  748 — Complications  in  Tenotomy  Operations, 
749 — Partial  or  Graduated  Tenotomy,  749 — Advancement  or  Readjust- 
ment, 750 — Reese's  Muscle-resection  Operation,  754 — Operation  for 
Shortening  the  Tendon,  756 — Advancement  of  the  Capsule  of  Tenon, 
756 — Operations  upon  the  Lacrimal  Apparatus,  757 — Slitting  the 
Canaliculus,  757 — Introduction  of  the  Lacrimal  Probe,  757 — Incision  of  a 
Stricture,  758 — Introduction  of  the  Lacrimal  Syringe,  758 — Curettage 
in  Dacryocystitis,  758 — Excision  of  the  Lacrimal  Sac,  758 — Extirpation 
of  the  Lacrimal  Gland,  760 — Extirpation  of  the  Palpebral  Portion  of  the 
Lacrimal  Gland,  761 — Toti's  Operation,  761 — West's  Operation,  761 — 
Mosher's  Operation,  761. 

APPENDIX 

The  Use  of  the  Ophthalmometer,  763 — The  Use  of  the  Tropometer, 
766 — ^Locahzation  of  Foreign  Bodies  in  the  Eveball  with  the  Rontgen 
Ravs,  768. 


Index 775 


DISEASES  OF  THE  EYE 


CHAPTER  I 
GENERAL  OPTICAL  PRINCIPLES 

Transmission  of  Light. — By  light  is  meant  that  physical  force 
or  form  of  energy  which,  acting  on  the  sentient  elements  of  the  retina, 
causes  the  mental  perception  of  the  specific  energy,  that  is,  sight  or 
vision. 

From  each  point  of  the  surface  of  a  luminous  body  light  or  rays  of 
light  proceed  in  straight  lines  in  all  directions,  and  in  order  to  explain 
the  transmission  of  light  it  is  assumed  that  throughout  the  universe 
there  exists  an  exceedingly  tenuous  matter  to  which  the  term  ether  is 
apphed  (see  page  21).  Exactly  what  the  vibrating  disturbances  are 
which  constitute  light  is  not  certainly  known. 

Refraction. — By  refraction  of  light  is  meant  the  alteration  which 
takes  place  in  the  direction  of  luminous  rays,  which  pass  obliquely 
from  one  medium  into  another  of  different  density. 

A  ray  of  light  passing  through  air  keeps  the  same  direction  until 
it  strikes  obliquely  the  surface  of  a  denser  medium,  when  its  course  is 
changed  toward  the  perpendicular  to  that  surface.  If  this  denser 
medium  is  a  piece  of  glass  bounded  by  parallel  sides,  the  ray,  as  it 
passes  through  the  second  surface,  is  bent  back  again  into  the  rarer 
medium. 

Rays  passing  from  a  denser  into  a  rarer  medium  are  deviated  from 
the  perpendicular.  The  ray  now  has  a  direction  parallel  to  its  original 
course;  the  sides  being  parallel,  the  deviation  at  each  surface  is  equal 
in  extent,  but  opposite  in  direction  (Fig.  1). 

If  the  denser  medium  is  bounded  by  oblique  surfaces,  the  devia- 
tion at  the  second  surface  does  not  restore  the  ray  to  its  original  direc- 
tion, but  it  still  more  increases  the  alteration  of  its  direction  (Fig.  2). 

Index  of  Refraction.— The  deviation  of  the  ray  from  its  course 
depends  upon  the  difference  in  the  density  of  the  two  media. 

A  ray  passing  obliquely  from  one  medium  into  another  of  the  same 
density  is  not  bent  from  its  course.  The  relative  resistance  of  a  sub- 
stance to  the  passage  of  light  is  expressed  by  its  index  of  refraction. 
The  absolute  index  of  refraction  is  its  resistance  as  compared  with 
vacuum;  but  as  there  is  very  little  difference  between  the  indices  of 
refraction  of  air  and  of  vacuum,  air  is  considered  as  Ifor  all  calculations 
in  lenses. 

2  17 


18 


GENERAL   OPTICAL    PRINCIPLES 


As  the  difference  in  the  density  of  the  two  media  increases,  the  ray 
is  bont  more  sharply  from  its  course,  and  the  angle  it  forms  with  the 
perpendicular  after  refraction  by  a  denser  medium  is  proportionally 
smaller  than  the  angle  formed  by  the  ray  before  refraction. 


Fig.  1. ^Refraction  of  light  through  a  plate  of  glass  bounded  by  plane  surfaces 
which  are  parallel:  A-B  is  the  incident  ray;  B-C,  the  same  ray.  refracted  by  the  first 
surface,  nearer  to  the  perpendicular,  P-P;  C-D,  the  same  ray,  refracted  by  the  second 
surface,  becomes  parallel  to  A-B,  its  original  direction.  The  ray  H-K,  perpendicular 
to  the  surfaces  B  and  C,  undergoes  no  refraction. 

The  angle  formed  by  the  ray  with  the  perpendicular  to  the  surface 
of  the  second  medium  is  called  the  angle  of  incidence — angle  /.     The 
angle  formed  by  the  ray  with  the  perpendicular  after  refraction  is 
called  the  angle  of  refraction — angle  7^.     The  sine  of  the  angle  of  inci- 
dence,   divided    by   the   sine  of  the 
angle  of  refraction,  gives  the  index 
of    refraction.     Glass    used    in    the 
manufacture    of    spectacles    has    an 
index  of  refraction  of  about  1.53. 

Prisms. — A  prism  is  a  portion  of 
iiilass  or  other  refracting  substance 
bounded  by  two  plane  surfaces  which 
are  inclined  to  each  other,  forming  an 
angle,  which  is  called  the  refracting 
angle,  or  simply  the  angle  of  the  prism 
(P'ig.  2,  a),  and  is  expressed  in  de- 
grees. Prisms  are  often  designated  by  the  numbers  of  degrees  in  the 
refracting  angle. 

The  sides  of  the  prism  converge  to  a  (bin  (>dge  at  one  extremity, 
called  the  apex  (Fig.  2,  A);  at  the  other  extremity  they  diverge  from 
each  other  and  form  the  6a.se  (Fig.  2,  B-C). 

Refraction  Through  a  Prism.  If  a  ray  of  light  from  an  object 
(J"'ig.  2,  O;  ]);isses  thioiiuli  a  ])rism  the  refractive  index  of  which  is 
greater  than  air,  the  deviation  is  always  from  the  ii\)v\  to  wan!  the 
base  of  the  prism. 

To  the  eye  of  an  ol)ser\'er  ])laced  at  the  other  side  of  the  i)rism 
(l''ig.  2,  K)  the  refincted  lay  seeiiis  (it  coiue  fioiii  the  direction  of  the 


Fig.  2.  —  Refraction  through  a 
denser  medium  having  oblique  sur- 
aces.  At  each  surface  the  ray  is  bent 
toward  the  base  of  the  figure. 


NUMBERING   OF   PRISMS  19 

apex  (Fig.  2,  0'),  since  a  ray  is  projected  backward  over  the  course 
given  to  it  by  its  last  refraction,  and  a  single  object  appears  double 
if,  with  both  eyes  open,  a  prism  of  sufficient  strength  is  placed  before 
one  of  them.  The  angle  which  the  ray  in  this  last  direction  forms 
with  the  ray  in  its  original  direction  is  called  the  angle  of  deviation. 

When  one  eye,  on  account  of  muscular  weakness,  is  unable  to  direct 
its  visual  Hne  to  the  point  of  fixation,  a  prism  will  alter  the  direction 
of  the  ray  from  the  point  of  fixation  so  that  it  coincides  with  the  visual 
line  of  the  weaker  eye.  The  refractive  properties  of  a  prism  are  utihzed 
to  test  the  strength  of  the  ocular  muscles,  that  is,  to  ascertain  prism- 
convergence,  prism-divergence  and  sursum- 
vergence  (see  pages  75  and  76),  to  estimate 
the  balance  of  the  exterior  e3'e  muscle  (see 
pages  75,  78  and  610),  to  neutralize  the 
diplopia  caused  by  abnormal  deviation  of 
the  visual  hne — for  example,  in  parah'tic 
strabismus  and  in  the  treatment  of  hetero- 
phoria  (see  page  614) — to  detect  malingerers 
who  feign  monocular  bhndness  (see  page 
557) ,  and  in  the  apphcation  of  the  Wildbrand-      ,  ^'^•.  ^-Deviation    pro- 

^ '  '^^  ...  duced  by  a  prism :  /,  Angle  of 

Saenger    test    to    determme    the    situation    of       incidence;  72,  angle  of  refrac- 

the  lesion  in  hemianopsia  (see  page  571).  ^^°'^''  ^<  angle  of  deviation; 

Angle  of  Deviation.-The  angle  of  de-     ^Z  l.^.^r^'^^tj:^- 
viation  is  the  angle  formed  by  the  incident     son). 
ray  with  the  refracted  ray.     The  amount  of 

this  angle  is  somewhat  more  than  one-half  of  the  refracting  angle  of 
the  prism  for  all  prisms  between  1°  and  10°,  but  for  practical  purposes 
the  two  maj'  be  considered  equal.  Above  this  the  deviation  rapidly 
increases. 

When  the  angle  of  incidence,  formed  by  a  ray  in  the  interior  of  a  ,- 
prism,  amounts  to  40°  49',  the  angle  of  refraction  equals  90°;  the  angle 
of  deviation,  the  difference  between  the  two,  then  equals  49°  11'. 
When  the  refraction  which  takes  place  at  each  surface  of  a  prism  is 
equal,  the  minimum  amount  of  deviation  is  present.  When  the  ray  is 
perpendicular  to  one  surface,  the  angle  of  incidence  at  the  second  sur- 
face equals  the  angle  of  the  prism;  the  deviation  is  greater  in  this 
case,  as  all  the  refraction  takes  place  at  one  surface.  A  table  of  the 
minimum  deviation  of  prisms  is  given  on  page  20. 

Numbering  of  Prisms. — The  designation  of  prisms  by  their 
angular  deviation,  instead  of  by  their  refracting  angles,  was  urged  by 
Dr.  Edward  Jackson,  of  Denver,  before  the  Ninth  International  Med- 
ical Congress.     Two  methods  of  accomplishing  this  have  been  proposed : 

Dennett's  Method:  The  Centrad. — Dr.  William  S.  Dennett's 
calculation  has  for  its  base  an  arc  called  th.e  radian,  whose  length  equals 
the  radius  of  its  curvature.  Such  an  arc  equals  57.295°.  A  prism 
which  will  produce  an  angular  deviation  of  the  one-hundredth  part 
of  this  arc  is  called  one  centrad,  denoted  by  the  sign  V .  The  deviation 
of  such  a  prism  would,  therefore,  be  0.57295°.     The  merit    of  this 


20  GENERAL   OPTICAL    PRINCIPLES 

method  consists  in  the  unitormity  of  the  deviation.  10  centrads  having 
exactly  ten  times  the  deviation  of  1  centrad.  The  deviations  are  so 
many  hundredths  of  the  radius  measured  on  the  arc. 

Prentice's  Method:  The  Frism-diopter.-  Mr.  Charles  F.  Prentice 
proposes,  as  the  standard  of  deviation,  a  prism  which  shall  deflect  a 
ray  of  light  1  cm.  at  a  plane  1  meter  distant — that  is,  the  hundredth 
part  of  the  radius  measured  on  the  tangent.  This  he  calls  the  prii<m- 
(liopter,  denoted  by  the  sign  A.  The  value  of  the  centrad  ami  prism- 
diopter  are  given  below  (see  table). 

There  are  two  practical  advantages  connected  with  the  method 
of  Mr.  Prentice  which  also  can  l>e  applied  to  the  centrad.  The  pris- 
matic deviation  of  a  decentered  lens  may  be  very  readily  found,  as 
Prentice  has  shown  by  the  following  rule:  If  a  lens  be  decentered  1  cm., 
the  prismatic  deviation  of  the  lens  will  be  equal  to  as  many  prism- 
diopters  as  the  number  of  diopters  in  the  lens.  Thus,  if  a  4-diopter 
lens  be  decentered  1  cm.,  the  prismatic  deviation  will  be  4  prism- 
diopters,  or  4  centrads,  since  centrad  and  prism-diopter  equal  each 
other.  The  same  lens  decentered  0.5  cm.  would  produce  2  prism- 
diopters  or  centrads  of  deviation. 

Table  of  Relative  Values  of  Centrads  and  Prism-diopters,  Prepared  by 

James  Wallace 

Centrads  Pnsxn-diopters                        ^^Sm^V^e^.u^rllf  ""' 

1  1  1.06° 

2  2.0001  2.16° 

3  S.OOVS  3.24° 

4  4.0028  4.32° 

5  0.0045  5.40° 

6  6.00G3  6.47° 

7  7.0115  7.54° 

8  8,0172  8.62° 

9  9.0244  9.68° 
10  10.0:333  10.73° 
15  15.114  16.1° 
20  20.270  21   L3° 
40;  42.288  :i9.0073° 

The  prisms  represent  the  minimum  deviation  with  an  index  of  refraction  of  1.53. 

The  relation  to  the  meter  angle  (see  page  45)  is  also  very  simple. 
One-half  the  interpupillaiy  distance  is  the  sine  of  the  meter  angle. 
The  ratio  of  this  to  the  point  of  fixation  in  hundredths  giv(>s  neaily 
the  number  of  prism-diopters,  or  centrads  of  deviation,  (Mubrac-eii  in 
any  nundjer  of  meter  angl(>s.  For  example,  if  the  interpupillary  ilis- 
tance  is  60  mm.,  one-half  of  this  is  30  mm.;  assuming  the  amount  of 
convergence  to  be  4  meter  angles,  25  em.,  or  250  mm.,  is  the  distance 
of  the  point  of  fixation.  The  deviation  of  the  visual  line  then  is  30 
in  250,  or  12  in  100  =  12  centrads,  or  12  \\  I).  For  small  arcs  the 
tangent  and  the  sine  agree  very  closely  with  the  arc.  Foui'  nnMer 
angles  of  convergence  then  represent  12  ceiitiads  of  deviation  or  12 
prism-diopters. 


RAYS    OF    LIGHT 


21 


Rays  of  Light. — Any  luminous  point  diffuses  light  in  all  direc- 
tions in  straight  lines  called  rays.  As  the  rays  proceed  from  the  lumin- 
ous source,  those  which  diverge  from  one  another  become  more  widely 
separated  (Fig.  4). 

If  a  circular  aperture  1  cm.  in  diameter  be  made  in  a  metal  plate 
and  a  luminous  point  be  placed  at  different  distances  from  it — for  ex- 
ample, at  1  meter  and  at  10  meters — the  rays  coming  from  10  meters, 
which  pass  through  the  aperture,  will  be 
less  diverging  than  those  which  come 
from  1  meter.  A  cone  of  light  will  pass 
through  the  aperture  in  each  case,  but 
the  shape  of  it  will  be  different  according 
to  the  distance  of  the  hght  from  the  aper- 
ture in  the  screen.  When  the  round  hole, 
1  cm.  in  diameter,  is  1  meter  distant  from 
the  point  of  light,  the  cone  has  a  base 
1  cm.  in  diameter,  and  the  apex  is  sit- 
uated in  the  luminous  point  100  cm.  dis- 
tant. The  rays  have  diverged  1  cm.  in 
traveling  100;  the  metal  plate  has  cut 
off  all  other  raj's  having  a  greater 
divergence.  If  the  cone  of  light  passes 
falls  upon  a  distant  wall,  the  cone  will 

tions — viz.,  the  base  will  be  3^1  oo  of  the  altitude.  If  the  wall  be  5  times 
the  distance  of  the  screen  from  the  light,  a  luminous  circle  5  cm.  in 
diameter  will  be  formed  upon  the  wall.  If,  now,  the  light  is  removed 
to  a  point  10  meters  from  the  screen  (1000  cm.),  a  cone  of  light  is 
formed  whose  base  is  1  cm.  and  whose  altitude  is  1000.     The  rays 


Fig.  4. — Divergence  of  rays  from 
a  luminous  source  (Loring). 

through  the  aperture  and 
preserve  the  same  propor- 


FiG.  5. — Raj-s  diverging  from  the  candle  .4  pass  through  the  aperture  in  the  screen 
S,  and  form  the  cone  of  light  whose  base  is  the  distance  a-a'.  Rays  from  a  more  dis- 
tant candle,  B,  having  a  greater  divergence  than  b-b',  are  intercepted  by  the  screen  S 
(Wallace). 


which  pass  through  the  aperture  have  now  onl}^  }{o  of  the  divergence 
of  the  rays  in  the  former  case;  the  base  of  the  cone  is  }iooo  of  the  alti- 
tude. The  cone  of  light  will  now  form  a  circle  on  the  wall  5  meters 
beyond  the  aperture,  only  1.5  cm.  in  diameter.  If  the  point  of  hght 
be  at  a  very  great  distance,  there  will  be  no  difference  in  the  size  of 
the  luminous  circle  and  the  aperture  in  the  screen;  the  size  of  the  circle 
remains  about  1  cm.  on  the  wall  at  5  meters  from  the  screen.  The  rays, 
therefore,  have  a  nearlj^  parallel  direction.     This  is  shown  in  Fig.  5. 


22  GENERAL    OPTICAL    PRINCIPLES 

Rays  which  enter  the  pupil  of  the  eye  from  a  point  6  meters  distant 
have  so  httle  divergence  that  they  may  be  considered  parallel.  The 
average  size  of  the  pupil  being  4  mm.,  the  divergence  is  only  /eooo- 
All  rays  diverging  more  wideh'  than  this  are  excluded  by  this  width  of 
the  pupil. 

The  relation  to  the  eye  of  raj's  diverging  from  6  meters  or  coming 
from  an  infinite  distance  is  practically  identical,  but  for  lenses  of  long 
focal  distance  and  large  aperture  an  infinite  distance  is  required  in 
order  to  obtain  parallel  rays.  Thus  the  sun  and  stars  are  so  remote 
that  the  rays  coming  from  them  have  no  apprecial)le  divergence,  and 
they  are  considered  parallel. 

Parallel  rays  must  emanate,  as  has  been  explained  before,  from  a 
distant  object.  They  are  brought  together  by  a  lens  at  its  principal 
focus.  Conversely,  rays  which  diverge  from  the  principal  focus  of  a 
lens  are  parallel  to  one  another  after  being  refracted  by  the  lens. 

Divergent  rays  emanate  from  an  object  nearer  than  infinity.  A 
greater  refractive  power  must  be  exercised  to  bring  them  together  at 


J'Ki.   tj.      Leiisi'S  as  i>risii:s. 

the  same  distance  behind  a  lens  than  is  required  for  rays  which  are 
parallel;  consequently,  divergent  rays  are  united  at  a  point  farther 
than  the  principal  focus.  The  nearer  the  point  of  divergence  lies  to 
the  lens,  the  farther  away  from  the  lens  is  the  point  where  the  rays 
converge  to  a  focus. 

Convergent  rays  do  not  exist  in  nature.  Only  such  rays  are 
convergent  which  have  passed  through  a  convex  lens  or  have  been 
refh'cted  from  a  concave  mirror. 

Significance  of  the  Different  Rays.  The  refraction  of  llu>  eye 
is  (h'teniiiiied  l»y  the  character  which  the  rays  must  have  in  t)rder  to 
be  brought  to  a  focus  on  the  retina. 

An  eminctrojn'c  eye,  with  relaxed  accommodation,  requires  rays  to 
be  parallel  in  order  that  they  shall  meet  on  the  retina. 

A  myopic  eye  re(|uires  rays  to  (Mveige  fnim  some  near  point  in 
order  to  meet  on  its  retina. 


PRINCIPAL    FOCUS    OF    A    CONVEX    LENS  23 

A  hyperopic  eye  requires  rays  which  already  have  convergence  to 
some  point  in  order  to  unite  them  on  its  retina. 

An  emmetropic  eye  emits  parallel  rays. 

A  myopic  eye  emits  convergent  rays. 

A  hyperopic  eye  emits  divergent  rays. 

Lenses. — A  lens  is  a  portion  of  glass  or  other  transparent  substance 
bounded  by  two  curved  surfaces,  or  by  one  curved  surface  and  one 
plane  surface.  The  curved  surfaces  are  convex,  elevated  in  the  center, 
and  thin  at  the  edge;  or  they  are  concave,  hollowed  out  in  the  center 
and  thick  at  the  edge. 

A  lens  may  be  regarded  as  a  series  of  prisms  with  the  refracting 
angles  increasing  in  value  from  the  center  toward  the  periphery. 
(Fig.  6.) 

In  a  convex  lens  the  bases  of  the  prisms  are  directed  toward  the 
center  of  the  lens,  and  rays,  therefore,  are  refracted  toward  the  axis 
which  passes  through  the  center.  In  a  concave  lens  the  bases  of  the 
prisms  are  directed  away  from  the  center,  and  rays,  therefore,  are 
refracted  away  from  the  axis.  As  the  angles  increase  from  the  center 
outward,  the  peripheral  rays  will  be  refracted  more  than  the  central 
rays.  The  result  of  this  is  that  in  a  convex  lens  the  rays  after  refrac- 
tion converge  to  the  same  point,  the  increased  bending  of  the  more 
peripheral  rays  just  sufficing  to  compensate  for  their  greater  distance 
from  the  axis.     In  a  concave  lens  the  rays  diverge  more  widely  as  they 


Fig.  7. — Principal  focus  of  a  convex  lens.  The  parallel  rays  a,  b,  c,  d  are  refracted 
by  the  lens  so  as  to  unite  at  the  point  F  on  the  axis  P.  The  ray  P  undergoes  no  refrac- 
tion.    F  is  the  principal  focus. 

pass  through  the  peripheral  parts  of  the  lens,  with  the  result  of  making 
them  appear  to  have  diverged  from  a  common  point. 

Focus  of  a  Convex  Lens. — The  point  to  which  rays  converge 
after  refraction  by  a  convex  lens  is  called  its  focus. 

Principal  Focus  of  a  Convex  Lens. — The  principal  focus  of  a 
lens  is  the  focus  for  parallel  rays.  As  the  most  distant  rays  are  only 
parallel,  never  convergent,  the  principal  focus  is  the  shortest  focus, 
unless  the  lens  is  combined  with  another  convex  lens  or  concave  mirror. 
Rays  diverging  from  the  principal  focus  of  a  lens  are  rendered  parallel 
after  passing  through  the  lens,  and  come  to  a  focus  at  an  infinite 
distance. 


24 


GENERAL    OPTICAL    PRIN'CIPLES 


Conjugate  Focus  of  a  Convex  Lens. — Wlien  rays  diverge  from 
any  point  nearer  than  infinity,  they  are  brought  together  at  a  point 
on  the  other  side  of  the  lens  farther  than  the  prineipal  focus.  The 
point  from  whicli  rays  diverge  and  the  point  to  which  tliey  converge 
are  called  conjugate  foci.  As  the  point  of  divergence  approaches  the 
lens  the  point  of  convergence  recedes;  wluni  the  point  f)f  divergence  is 


Fig.  8. — Conjugate  focus  of  a  convex  lens.  The  two  dots  in  the  axis  represent  the 
principal  foci,  one  being  marked  F.  Rays  diverging  fromO  converge  after  refraction  to 
the  point  F',  farther  than  the  principal  focus.  Rays  from  F'  also  converge  after  refrac- 
tion to  O.     0  and  F  are  conjugate  foci. 

at  twice  the  focal  distance  of  the  lens,  the  point  of  convergence  is  at  an 
equal  distance  on  the  other  side.     The  conjugate  foci  are  how  ettual. 

As  the  point  of  divergence  approaches  still  closer  the  point  of  con- 
vergence is  at  a  greater  distance,  until,  when  the  point  from  which  the 
rays  diverge  is  at  the  principal  focus,  the  rays  converge  at  an  infinite 
distance. 

Rays  diverging  from  either  of  these  points  converge  toward  the 
other.     When  ra3's  diverge  from  a  point  whose  distance  is  equal  to  or 


Fig.  9. — Virtual  ioriis  of  a  convex  lens.  Kays  from  the  point  U,  less  than  the  prin- 
cipal focal  distance,  diverge  after  refraction  as  if  they  came  from  the  point  V.  V  is  the 
virtual  focus  of  O. 

greater  than  the  principal  focus,  the  conjugate  focus  is  positire. 
When  llic  distance  is  less  than  the  principal  focus,  the  conjugate  focus 
is  negatiir. 

Virtual  Focus  of  a  Convex  Lens. — When  rays  diverge  inuu  some 
point  nearer  to  a  lens  than  its  principal  focus,  the  raj^s  after  refraction 
still  continue  divergent.  These  (iiv(>rgent  rays,  if  traced  backward, 
would  meet  in  a  point  on  the  same  side  of  the  lens  from  which  tiiey 
(liverg('(|.  'IMiis  point  is  called  a  negative,  oi-  rirtual,  focus,  hec.-iuse  the 
rays  do  not  really  meet  here,  hut  are  given  a  direclion  by  (he  lens  .-is 
if  I  hey  had  (n\('r^('(l   from   this  point    ( l-'ig.  U).     'rhcrt-torc  the  [)oint 


FORMATION    OF    IMAGES   BY    A    LENS :    OPTICAL    CENTER        25 

from  which  rays  diverge  and  the  point  to  which  they  converge  are  focal 

points. 

Foci  of  Concave  Lenses. — The  foci  of  concave  lenses  for  parallel 
or  divergent  rays  are  virtual,  or  negative.  They  are  the  points  from 
which  the  rays  seem  to  cHverge  after  passing  through  the  lens. 


Fig.  10. — Principal  focus  of  a  concave  lens.  Parallel  rays  o,  b,  d,  e,  after  refraction 
by  the  concave  lens  L,  are  rendered  divergent  as  if  they  came  from  the  point  F  on  the 
axis  c.     The  ray  c  is  not  refracted.     F,  the  principal  focus  of  a  concave  lens,  is  virtual. 

Principal  Focus  of  a  Concave  Lens. — When  parallel  rays  fall 
upon  a  concave  lens  they  are  rendered  divergent.  If  these  rays  be 
traced  backward,  they  will  seem  to  have  diverged  from  a  point  near 
the  lens.     This  point  is  the  principal  focus  (Fig.  10). 


Fig.  11. — 0,  Optical  center  of  lens.  The  point  C"  is  the  center  of  curvature  for  the 
surface  S".  The  point  C"  is  the  center  of  curvature  for  the  surface  S'.  A  ray  passing 
from  C"  to  C"  would  be  perpendicular  to  both  surfaces.  It  would  pass  through  without 
de-s-iation.     This  ray  is  called  the  axial  ray,  or  axis. 

The  radii  C"-J"  and  C'-J',  being  parallel,  a  ray  in  the  lens  passing  in  the  direction 
J'-J"  must  form  equal  angles  at  the  two  surfaces.  The  point  where  this  ray  intersects 
the  axis  is  the  optical  center  (Landolt) . 

Conjugate  foci  of  concave  lenses  are  also  virtual  and  found  in  a 

similar  manner. 

Formation  of  Images  by  a  Lens:  Optical  Center.— In  the  lens 
(Fig.  11)  the  point  0  on  the  axis  is  called  the  optical  center.     Any  ray 


26 


GENERAL    OPTICAL    PRINCIPLES 


passing  through  this  point  is  refracted  equally  at  both  surfaces,  since  it 
forms  equal  angles  with  the  radii  of  the  two  surfaces.  The  direction 
of  the  ray  is,  therefore,  the  same  after  refraction  by  the  second  surface 
as  it  was  before  refraction  by  the  first.  P'or  thin  lenses  it  may  be  said 
that  any  ray  directed  to  the  optical  center  passes  through  without 
deviation.     These  rays  are  called  secondary  axes. 


Fig. 


i  .^..  12. — Position  and  size  of  image  formed  by  convex  lens.  The  ray  A.  A','  from 
the  point  A,  being  directed  to  the  optical  center  of  the  lens,  continues  its  course  in  a 
parallel  direction,  K"-A".  Another  ray  passing  from  .4  parallel  to  the  axis  L',L",  is 
refracted  through  ^",  the  principal  focus,  and,  intersecting  the  ray  A-K"-A",  deter- 
mines the  position  of  the  image  of  the  point  A.  Still  another  ray  passing  from  A  through 
the  anterior  principal  focus  <p',  after  refraction,  is  parallel  with  the  axis  L'-L",  and  meets 
the  other  rays  in  the  point  .4"  (Landolt). 

The  ray  drawn  from  any  point  in  an  object  to  the  optical  center  of 
a  lens  gives  the  line  on  which  the  image  of  the  point  is  to  be  found.  A 
ray  from  the  same  point  in  the  object,  passing  parallel  to  the  axis  of  the 
lens,  would  be  refracted  through  the  principal  focus  of  the  lens,  since 
the  principal  focus  is  the  focus  for  parallel  rays  (Fig.  12). 


Fig.   13. —  Image  formed  \>y  a  convex  lens:  OB  is  the  object;  U'-Ii'  is  the  inxoricd  image. 

In  order  to  fhid  the  position  and  size  of  an  inuige  formed  by  a  lens 
it  is  only  necessuiy  to  diaw  two  lines  from  eacii  extremity  of  the  object: 
one  passes  through  the  optical  center  of  the  lens,  and  the  other,  parallel 
with  the  axis  of  the  lens,  would  lie  refracted  to  the  principal  focus.  The 
position  of  the  image  is  fountl  at  the  points  where  the.se  lines  intersect. 

The  size  of  the  image  is  proportional  to  the  size  of  the  object  as  the 
distance  of  the  image  from  the  opti(;il  center  is  to  the  distance  of  the 
object  from   the   optical   center.      Wlu'ii    the  object    is  situated   at  a 


FORMATION  OF  IMAGES  BY  A  LENS :  OPTICAL  CENTER   27 

greater  distance  from  the  lens  than  its  principal  focus,  the  image  is  a 
real,  inverted  one.  . 

In  the  figure  (Fig.  13)  0-B  is  the  object;  the  rays  divergmg  from  0 
intersect  in  0',  which  is  the  position  of  the  image  of  the  point  0.  Simi- 
larly the  rays  from  A  unite  in  B',  the  position  of  the  image  of  the  pomt 
B;  B'-O'  is  the  image  of  0-B. 


Fig.   14.— Virtual  image  of  a  convex  lens:  C-D  is  the  object;  C'-D'  is  the  virtual  image. 

erect  and  magnified. 

When  the  object  is  situated  nearer  to  the  lens  than  its  principal 
focus,  the  image  is  a  virtual,  erect  one. 

The  virtual  image  of  a  convex  lens  appears  to  be  at  the  pomt  trom 
which  the  rays  refracted  by  the  lens  seem  to  have  diverged  (Fig.  14). 
From  the  point  C,  of  the  object  C-D,  the  ray  C-.S  is  parallel  to  the  axis. 
It,  therefore,  is  refracted  to  the  principal  focus,  P.  The  ray  C-0  passes 
through  unchanged.     By  projecting  these  rays  backward  they  meet  in 


Fig.   15.— Virtual  image  of  a  concave  lens:  O'-B'  is  the  virtual  image  of  the  candle,  O  B, 
erect  and  diminished  in  size. 

C,  the  image  of  the  point  C.  The  rays  from  the  point  D  seem  to^haye 
diverged  from  D\  An  enlarged,  erect  image  is  thus  formed  m  C  -D  . 
The  image  formed  by  a  concave  lens  is  mostly  virtual  and  dimin- 
ished. Two  rays,  proceeding  from  a  point  0,  in  the  object,  one  parallel 
to  the  axis,  which  seems,  after  refraction,  to  have  diverged  from  the 
principal  focus,  and  is  traced  backward,  and  the  other,  which  is  directed 
to  the  optical  center,  at  their  intersection,  denote  the  position  of  this 
point  in  the  image  (Fig.  15).     The  enlarged  image  formed  by  a  convex 


28  GENERAL    OPTICAL    PRIN'CIPLES 

lens,  and  tho  diniinishod  imap;c  formed  by  a  concave  lens,  as  described 
in  the  preceding  paragraph,  are  among  the  most  obvious  effects  of  such 
lenses  as  they  are  ordinarily  used.  It  must  l)e  remembered,  however, 
that  convex  lenses  are  not  essentiallj'  magnifiers  nor  concave  lenses 
essentially  minifiers,  ina.smuch  as  their  effect  on  images  depends  upon 
their  position  with  reference  to  optical  .systems  which  they  supplement. 

Focal  Distance  of  a  Lens. — The  distance  from  the  optical  center 
of  a  lens  to  the  focal  point  is  called  the  focal  (listance. 

The  length  of  this  depends  upon  the  radii  of  curvature  of   the 

surfaces  of  the  lens  and  on  its  index  of  refraction.     Representing  the 

radius  by  r,  the  index  of  refraction  of  the  lens  by  n,  that  of  air  being 

r 

1,  F  =  ~. -^  IS  the  formula  for  obtaming  the  focus  of  a  bispheric 

2(n  —  1) 

convex   or   concave   lens.     The   formula   for   a  planospheric  lens  is 

T 
F  =  -         .     The  refraction  is  effected  at  one  surface  if  the  ravs  are 
n  —  I 

parallel  as  they  enter  or  pass  from  the  plane  surface;  otherwise  refraction 

occurs  at  the  plane  as  well  as  at  the  curved  surface. 

Numeration  of  Lenses. — The  refractive  power  of  a  lens  is  the 
inverse  of  its  focal  distance.  If  the  refractive  power  of  a  lens  whose 
focal  distance  is  1  meter  is  represented  bj^  1,  then  a  lens  whose  focal 
distance  is  2  meters  has  only  one-half  the  refractive  power  of  the  first, 
since  the  rays  are  not  bent  so  sharply  by  the  second  lens.  Again,  if  a 
lens  bends  rays  so  sharply  that  they  meet  the  axis  at  0.5  meter  distance, 
its  refractive  power  is  twice  that  of  a  lens  of  1  meter  focus. 

The  focus  of  a  biconvex  lens  (with  equal  radii),  made  of  glass  with 
an  index  of  1.50,  has  the  same  length  as  the  radius  of  curvature. 

F    =    ^; 


2(n  -  1)       2(1.50  -  1) 
F  =  r. 

Glass  used  in  spectacle  lenses  has  an  index  of  1.53,  consequently — 

F=     ' 

l.(K) 

r  =   l.()()F. 

In  the  old  system  tlic  lenses  were  marked  according  to  their  radii 
(jf  curvature  in  Paris  iiiciies,  and  the  focal  distance  was  somewhat  less 
than  the  radius  of  curvature.  As  all  the  leiiJ^es  in  use  had  longer  focal 
distances  than  1  inch,  they  were  fractions  of  tlie  refractive  power  of  a 
lens  of  1  inch  focus — viz.,  )  i,  ^4,  \s,  ^  I6.  <*^^'- 

In  1807  Nagel  proposed  to  number  lenses  by  their  refractive  power. 
By  adopting  as  a  standard  a  lens  of  longer  focal  distance  than  1  inch — 
viz.,  1  meter  (40  inches)  the  greater  number  of  lenses  are  made  nudti- 
ples  of  refractive  power  of  the  standard,  and  are  based  on  their  focal 
l(!ngths  in  meters  and  fractions  of  a  meter,  instead  of  being  based  on 
their  radii  of  eui\atuie. 


NUMERATION    OF    LENSES 


29 


The  term  diopter  was  proposed  by  Monoyer  for  a  lens  of  1  meter 
focus.  A  lens  of  2  meters  focus  is  only  J^  the  refractive  power,  or 
0.50  D.  The  present  scale  of  lenses  usually  comprises  a  series  from  0.12 
to  22  D.  Between  0.12  and  1.25  D  the  lenses  have  an  interval  of 
0.12  D.  From  1.25  to  5  D  the  interval  is  0.25  D;  from  5  to  8  D  an 
interval  of  0.50  D;  from  8  to  18  D  an  interval  of  1  D;  and  from  18  to 
22  D  the  interval  is  2  D.  This  uniformity  in  the  intervals  between  the 
lenses  is  an  important  advantage  over  the  old  system,  in  which  the 
lack  of  uniformity  in  this  respect  was  a  conspicuous  feature. 


Number  of  lens 

Focal  distance  in 

Focal  distance  in 

Nearest  corre- 

in diopters 

millimeters 

English  inches 

sponding  lens  in 
old  system 

0.12 

8000 

314.96 

0.25 

4000 

157.48 

144 

0.37 

2666 

104.99 

0.50 

2000 

78.74 

72 

Interval  of  0.12  D... 

0.62 

1600 

62.99 

60 

0.75 

1333 

52.5 

48 

0.87 

1143 

44.99 

42 

1 

1000 

39.37 

36 

1.12 

888 

34.99 

1.25 

800 

31.5 

30 

1.5 

666 

26.22 

24 

1.75 

571 

22.48 

2 

500 

19.69 

20 

2.25 

444 

17.48 

IS 

2.50 

400 

15.75 

16 

2.75 

363 

14.31 

15  or  14 

3 

333 

13.12 

13 

Interval  of0.25D...  . 

3.25 

308 

12.11 

12 

3.50 

285 

11.25 

11 

3.75 

267 

10.49 

10 

4 

250 

9.84 

9 

4.25 

235 

9.26 

8 

4.50 

222 

8.74 

8 

4.75 

210 

8.29 

5 

200 

7.87 

5.50 

182 

7.16 

7 

6 

166 

6.54 

Interval  of  0.5  D... 

6.50 

154 

6.06 

6 

7 

143 

5.63 

5 

7.50 

133 

5.25 

8 

125 

4.92 

9 

111 

4.37 

4.5 

10 

100 

3.94 

4 

11 

91 

3.58 

3.5 

12 

83 

3.27 

3.25 

Interval  of  1  D 

13 

77. 

3.03 

3 

14 

71 

2.8 

2.75 

15 

66 

2.64 

16 

62 

2.44 

2.5 

17 

59 

2.32 

2.25 

18 

55 

2.17 

Interval  of  2  D | 

20 
22 

50 
45 

1.97 
1.79 

2 

30 


GENERAL   OPTICAL   PRINCIPLES 


To  find  the  focal  length  of  any  lens  in  the  dioptric  system  divide 
1  meter,  or  100  cm.,  by  the  number  of  diopters:  thus  the  focal  length 

of  a  lens  of  5  D  is     _    =  20  cm. 
5 

In  the  old  .system  the  lenses  are  ground  with  a  radius  of  curvature 
in  Paris  inches.  The  focal  length  is  almost  exactly  the  same  in  English 
inches  as  the  radius  of  curvature  is  in  French  inches.  The  English  inch 
=  25.4  mm.:  the  French  inch  =  27.07  mm.;  25.4  X  1.06  =  26.92. 

In  column  three  of  the  table 
the  focus  is  given  in  English 
inches,  as  it  is  customary  to  com- 
pare the  French  lenses  with  the 
(li()l)t('rs  ])y  their  focal  length  in 
English  inches.  A  lens  of  1 
diopter  has  a  focal  length  of  39.37 
English  inches.  There  is  no  lens 
in  the  old  system  which  corres- 
ponds to  it  exactly.  The  nearest 
equivalent  would  be  a  lens  of  40 
inches. 

The  lenses  used  for  spectacles 
are  spheric  and  cylindric. 

Spheric  Lenses. — A  spheric 
lens  is  represented  by  a  section  of 
a  sphere,  or  of  two  sections  of  a 
sphere  placed  together  by  their 
plane  surfaces.  Light  passing 
through  a  spheric  lens  is  refracted 
ecjually  in  all  planes. 

Cylindric  Lenses. — A  cylin- 
dric lens  is  a  section  of  a  cylinder 
parallel  to  its  axis.  Light  passing 
through  a  cylindric  lens  is  not  re- 
fracted in  a  plane  parallel  to  its  axis,  but  in  a  plane  perpendicular  to 
the  axis;  rays  are  rendered  convergent  or  divergent  according  as  the 
cylinder  is  convex  or  concave  (Figs.  17,  18). 

Convex  lenses  are  designated  + ;  concave  lenses,  — . 
Toric  Lenses. — A  solid  developed  by  the  revolution  of  a  circle 
about  any  axis  other  than  its  diameter  is  known  as  a  torus.  A  toric 
leufi  may  be  described  as  one  which  is  cut  from  a  toric  surface  by  a 
|)laiie  parallel  to  its  axis  of  development.  The  optical  centering  of 
such  a  lens  retpiires  that  both  its  centers,  the  center  of  its  circle  and 
the  center  about  which  in  its  development  the  circle  revolves,  siiall 
be  on  the  axis  of  the  .system  (W.  S.  n(Minett).  With  the  toric  lens  the 
angle  of  distinct  view  is  increased,  Itiit  a  (('rtaiii  amount  of  astigmat- 
ism remains  in  the  gicater  iiumlx'r  of  powers.  To  eliminate  this 
astigmatism  of  obli(|ue  pencils  of  light  M.  von  Hohr  has  deveKiped  a 
lens  which  it   is  claimed  "repi'oduees  ;iii>'  gi\eii  (jetinite  point   of  an 


Fig.  10. — 1.  Biconvex  leas.  U.  Plano- 
convex lens.  3.  C'oncavoconvex  lena,  con- 
vergent meniscus.  4.  Biconcave  lens.  5. 
Planoconcave  lens.  6.  C'onvexoconcavo 
lens,  divergent  nienis.-us. 


COMBINATION    OF    LENSES 


31 


object  as  a  distinct  point  in  the  image,  that  is,  a  lens  which  is  corrected 
for  astigmatism  over  the  entire  field  of  vision  in  all  powers."  To  this 
lens  the  name  Punktal  has  been  given. 


Fig.  17. — Convex  cylindric  lens,  formed  by  a  section  of  a  cylinder  parallel  to  its 
axis,  which  acts  like  a  plane  lens  (1,  2,  3,  4),  in  a  direction  parallel  to  the  axis  of  the 
cylinder  (A,  B),  and  like  a  convex  lens  (o,  b,  c),  in  a  direction  perpendicular  to  the  axis. 

Combination   of   Lenses.— If  two  or  more  lenses  are  placed 
together,'for  example,  +  2  diopters,  +  3  diopters,  and  +  4  diopters. 


Fig.  18.— Concave  cylindric  lens,  formed  from  a  solid  cylinder;  in  a  plane  paralle 
to  the  axis  it  acts  like  a  plane  lens  (1,  2,  3,  4)-  but  in  a  plane  perpendicular  to  the  axis 
like  a  concave  lens  (c,  b.  c,  d). 

the  combination  forms  a  dioptric  power  equal  to  their  sum— viz.,  9 
diopters;  such  a  combination  has,  if  composed  of  thin  lenses,  a  focal 


32  GENERAL    OPTICAL    PRINCIPLES 

distance  of  ^Ij"  =  11  cm.  If  those  lenses  are  placed  at  their  focal  dis- 
tance from  an  object,  the  rays  cominj;  from  the  object,  after  passing 
through  the  lenses,  are  parallel. 

Two  or  more  concave  lenses  placed  together  likewise  produce  a 
dioptric  effect  equal  to  their  sum. 

Combination  of  Convex  and  Concave  Lenses. — If  a  concave 
and  a  convex  lens  of  ecjual  strenjith  are  placed  together,  they  will 
neutralize  each  other  so  exactly  that  a  distant  object  viewed  through 
them  will  appear  neither  enlarged  nor  diminished,  and  there  will  be  no 
prismatic  deviation  on  gently  shaking  the  lenses  in  a  direction  parallel 
to  the  surface. 

Should  they  be  unequal  in  strength,  on  shaking  them  an  object 
(the  edge  of  a  window  frame  is  suitable)  will  be  displaced  toward  the 
center  of  the  lens  if  the  concave  is  stronger,  and  away  from  the  center 
if  the  convex  is  stronger.  The  value  of  the  combination  will  be  the 
tlifference  between  the  strength  of  the  two.  For  instance,  a  +  3 
diopter  and  a  —  2  diopter  equal  +  1  diopter;  a  +  2  diopter  and  a  —  4 
diopter  =  —  2  diopter. 

A  —  2-diopter  lens  gives  to  parallel  rays  a  direction  as  if  they  came 
from  a  point  50  cm.  away.  Converseh',  rays  diverging  from  any  near 
point  may  be  represented  by  a  concave  lens,  the  principal  focus  of 
which  equals  that  distance.  Let  rays,  for  example,  diverge  from  a 
point  15  cm.  away;  they  evidently  are  similar  to  parallel  rays  which 
have  passed  through  a  concave  lens  of  15  cm.  focal  distance,  ^^^^is  = 
6.66  diopters. 

If  it  is  desired  to  find  the  conjugate  focal  flistance  of  any  lens  for 
rays  which  diverge  from  15  cm.,  6.66  should  be  subtracted  from  the 
dioptric  power  of  the  lens;  the  remainder  gives  a  lens  the  focal  distance 
of  which  is  the  conjugate  desired.  If  it  is  desired  to  find  the  conjugate 
focal  distance  of  a  12-diopter  lens  for  rays  which  diverge  from  15  cm., 
6.66  should  be  subtracted  from  12  =  5.38  diopters;  18.8  cm.  is  the 
conjugate  focal  distance. 

Combination  of  Cylindric  Lenses  with  Spheric  Lenses. — A 
cylindric  lens  is  curved  only  in  the  direc-tion  fnrpcndicular  to  //.v  axis; 
rays  which  enter  the  lens  are  refractetl  in  this  plane  to  the  focus  of  the 
lens  exactly  as  in  the  case  of  a  spheric  lens. 

In  the  opposite  direction,  that  is,  parallel  to  its  axis,  the  surface  of  a 
cylindric  lens  is  flat;  rays  entering  are  not  refracted  in  this  plane,  but 
pass  througii  uncliangcd.  The  effect  of  a  cylindric  lens  placed  in  front 
of  the  eye  is  to  increase  or  diminish  its  refraction  in  the  (hrection  at 
right  angles  to  its  axis,  but  in  the  opposite  direction  the  refractive 
power  is  unchanged  (see  Figs.  17,  18). 

A  convex  4-(hopler  cylindric  lens,  with  its  axis  in  a  vertical  (hrec- 
tion (written  -f  4  1)  cyl.,  axis  90°),  increases  the  refraction  in  the  hori- 
zontal direction  4  diopters,  but  tloes  not  alter  the  refraction  in  the 
vertical  (hrection.  The  horizontal  plane  is  expressed  by  the  term 
Jiorizonlal  miridian;  the  vertical  plane  by  the  term  virtical  meridian. 

A  concave  cylindric  lens  of  4  diopters,   with  its  axis  horizontal 


COMBINATION  OF  CYLINDRIC  LENSES  WITH  SPHERIC  LENSES    33 

(written  —  4  D  cyl.,  axis  180°),  diminishes  the  refraction  of  the  vertical 
meridian  4  diopters,  but  does  not  affect  the  refraction  of  the  horizontal 
meridian. 

A  convex  lens  of  3  diopters,  combined  with  a  convex  cylindric  lens 
of  2  diopters,  with  its  axis  vertical  (written  +  3  D  O  +  2  D  cyl., 
axis  90°),  adds  to  the  horizontal  meridian  +  5  diopters,  but  to  the 
vertical  meridian  only  3  diopters. 

The  combination  of  a  convex  spheric  lens  with  a  concave  cylindric 
lens  has  the  following  effect:  In  the  direction  parallel  to  the  axis  of 
the  cylinder  the  combination  equals  the  full  refraction  of  the  spheric; 
in  the  direction  at  right  angles  to  the  axis  of  the  cylinder  the  refraction 
is  equal  to  the  difference  between  the  two  lenses.  If  the  convex 
spheric  is  stronger  than  the  concave  cylinder,  the  difference  is  still 
represented  by  a  convex  glass.  For  example,  +  2  D  sph.,  O  —  1-50  D 
cyl.,  axis  180°  =  +  0.50  D  sph.,  C  +  1.50  D  cyl.,  axis  90°,  because 
+  2  D  in  the  meridian  of  180°  is  not  diminished,  but  in  the  meridian 
of  90°  it  is  reduced  to  +  0.50  D.  Now,  +  0.50  D  sph.  produces  this 
amount  of  refraction  at  90°,  and  supplies  +  0.50  D  of  the  requisite 
+  2  D  at  180°,  leaving  +  1.50  D  to  be  supplemented  by  a  cyhndric 
lens  with  its  axis  at  90°. 

In  place  of  writing  +  2  D  sph.,  O  —  1.50  D  cyl.,  axis  180°,  a  more 
simple  expression  would  be  +  0.50  D  sph.,  O  +  1.50  D  cyl.,  axis  90°. 

Where,  however,  the  concave  cylindric  lens  is  stronger  than  the 
convex  spheric,  the  difference  is  represented  by  a  concave  lens,  thus 
+  3  D  sph.,  O  —  6.50  D  cyl.,  axis  180°,  signifies  in  the  horizontal  mer- 
idian convex  3  D,  and  in  the  vertical  meridian  concave  3.50  D.  It  is 
necessary  to  combine  a  convex  with  a  concave  lens  in  order  to  obtain 
this  effect.  The  refractive  power  of  this  combination  can  be  expressed 
in  three  different  ways: 

+  3  D  sph.,  C  -  6.50  D  cyl.,  axis  180°. 

-  3.50  D  sph.,  C  +  6.50  D  cy].,  axis  90°. 

+  3  D  cyl.,  axis  90°,  C  -  3.50  D  cyl.,  axis  180°. 

In  the  first  combination  +  3  D  sph.  gives  the  +  3  D  necessary  for 
the  horizontal  meridian,  but  increases  the  refraction  of  the  vertical 
meridian  3  D  instead  of  diminishing  it;  therefore  the  —  6.50  D  cyl., 
axis  180°,  expends  3  D  of  its  refractive  power  in  neutralizing  the  effect 
of  the  +  3  D  sph.,  and  with  the  remainder  diminishes  the  refraction 
of  the  vertical  meridian  3.50  D. 

In  the  second  combination,  —  3.50  D  sph.,  O  +  6.50  D  cyl.,  axis 
90°,  the  concave  spheric  lens  diminishes  the  refraction  of  the  vertical 
meridian  3.50  D,  but  also  diminishes  the  refraction  of  the  horizontal 
meridian  3.50  D;  as  this  already  requires  +  3  D,  we  must  add  +  3.50  D 
more  to  compensate  for  the  concave  spheric,  making  +  6.50  D  cyl., 
axis  90°. 

In  the  third  combination,  +  3  D  cyl.,  axis  90°,  O  —  3.50  D  cyl., 
axis  180°,  +  3  D  cyl.,  axis  90°  increases  the  refraction  of  the  horizontal 
meridian  without  altering  the  refraction  of  the  vertical  meridian,  and 
the  —  3.50  D  cyl.,  axis  180°  diminishes  the  refraction  of  the  vertical 
meridian  without  affecting  the  refraction  of  the  horizontal. 

3 


34  GENERAL    OPTICAL   PRINCIPLES 

With  the  combination  of  a  convex  spheric  antl  cyhndiic  lens,  e.  g., 
+  3  D  sph.,  C  +  2  D  cyl.,  axis  90°,  a  concave  O.oO  D  cyhnder  with  its 
axis  at  right  angles  to  the  axis  of  the  convex  cylinder,  in  this  case  at 
180°,  diminishes  the  refraction  of  the  vertical  meridian  0.50  D,  the 
combination  then  equals  +  2.50  D  in  the  vertical  meridian  and  +  5  D 
in  the  horizontal  =  +  2.50  D  sph.,  C  +  2.50  D  cyl.,  axis  90°. 

A  convex  cylinder  +  0.50  D  atlded  to  the  same  combination,  with 
its  axis  at  right  angles  to  the  axis  of  the  first  cylinder,  that  is,  +  0.50  D 
cyl.,  axis  180°  with  +  3  D  sph.,  C  +  2  D  cyl.,  axis  90°.  increases  the 
refraction  in  the  vertical  meridian  +  0.50  D.  The  combination  then 
equals  +  3.50  D  in  the  vertical  meridian,  +  5  D  in  the  horizontal. 
This  is  obtained  by  +  3.50  D  sph.,  C  +  1.50  D  cyl.,  axis  90°. 

Visual  Angle. — The  apparent  size  of  an  object  depends  upon  the 
size  of  the  visual  angle. 

The  visual  angle  is  the  angle  formed  by  the  hnes  drawn  from  the 
two  extremities  of  an  object  to  the  nodal  point  of  the  eye.  The  nodal 
point  of  the  eye  is  analogous  to  the  optical  center  of  a  lens.  It  is  situ- 
ated 15  mm.  in  front  of  the  retina  and  7  mm.  behind  the  cornea.  Rays 
directed  to  this  pnint  pass  thro;!^;h  without  deviation. 


Fig.    19. — The  visual  angle. 

As  the  raj's  directed  to  the  nodal  point  of  the  eye  are  not  refracted, 
but  continue  the  same  course  until  they  strike  the  retina,  if  lines  are 
drawn  from  the  extremities  of  an  object  through  the  nodal  point  of  the 
eye,  and  continued  until  they  fall  upon  the  retina,  the  size  of  the  retinal 
image  of  the  object  is  obtained. 

The  figure  shows  that  the  ol)ject,  in  order  to  subtenil  the  same 
angle,  nmst  be  larger  the  farther  it  is  removed  from  the  eye.  The 
letter  A,  seen  clearly  at  6  meters,  would  have  to  be  three  times  as  large 
in  order  to  be  seen  distinctly  at  18  meters,  and  ten  times  as  large  in 
order  to  be  seen  clearly  at  (iO  m(>ters.  The  visual  angle  in  tlu>  three 
instances  remains  the  same. 

Retinal  Image  in  Emmetropia.  In  I  lie  enuuetropic  eye  the 
nodal  point  is  situated  7  nun.  beliiiid  the  cornea  and  15  nun.  in  front  of 
the  retina.  The  size  of  the  retinal  image  is  to  the  size  of  the  object  as 
the  distance  from  the  retina  to  the  nodal  point  (15  mm.)  is  to  the  dis- 
tance from  the  nodal  point  to  the  ohjcct.  Ther(>fore,  if  an  object  is 
situated  at  1  nn'tcr  distance  (  lOOO  niin.>,  its  iinaue  will  be  ^•''looo  of 
the  size  of  t  lie  ohicct . 


I 


MECHANISM    OF    ACCOMMODATION  35 

Retinal  Image  in  Ametropia. — In  the  hyperopic  eye,  the  axis  of 
which  is  shorter  than  that  of  the  emmetropic  eye,  the  retina  is  situated 
nearer  the  nodal  point;  the  image  is,  therefore,  smaller.  In  myopia 
the  axis  of  the  eye  is  longer;  the  retinal  image  is,  therefore,  larger. 

Visual  Acuteness;  Limit  of  Perception. — An  object  1  cm.  in 
size,  placed  1  meter  distant  from  a  normal  emmetropic  eye  (that  is,  an 
eye  without  any  error  of  refraction),  is  plainly  visible.  If  this  object  is 
moved  farther  and  farther  away,  it  forms  a  progressively  smaller  visual 
angle,  until  a  point  is  reached  beyond  w^hich  it  cannot  be  perceived, 
owing  to  the  diminutive  size  of  the  visual  angle.  The  limit  of  percep- 
tion has  now  been  reached. 

The  angle  which  the  object  subtends  at  this  distance  from  the  eye 
represents  the  maximum  acuteness  of  vision.  An  object  twice  the  size 
would  be  seen  distinctly  at  twice  this  distance.  An  object  one-half  the 
size  could  not  be  distinctly  seen  at  more  than  half  this  distance.  In 
general  terms  the  size  of  the  object  denoting  the  acuteness  of  vision  is 
always  proportional  to  the  distance. 

Normal  Acuteness  of  Vision. — Snellen  determined  the  normal 
acuteness  of  vision  to  be  the  power  of  distinguishing  letters  subtending 
an  angle  of  5'.  These  letters  are  formed  of  strokes  whose  width  is 
3^^  the  size  of  each  letter;  consequently  they  are  seen  under  an  angle  of 
only  1'.  The  openings  in  the  letters  and  the  spaces  between  contiguous 
strokes,  as  nearly  as  possible,  are  made  to  conform  to  the  same  angle. 


Fig.  20. — Two  of  Snellen's  test-types. 

The  relation  of  the  size  of  the  letter  to  the  distance  at  which  it 
should  be  discerned  by  a  normal  eye  is  expressed  by  twice  the  tangent 
of  half  the  angle  of  5'  =  0.001454.  The  size  of  a  letter  the  perception 
of  which  constitutes  normal  vision  at  a  given  distance  may  be  obtained 
by  multiplying  the  distance  by  0.001454.  At  the  distance  of  1  meter 
the  size  of  this  standard  letter  is  1.45  mm.  (0.001454  X  1000  mm.). 
At  a  distance  of  6  meters  the  size  of  the  letter  required  is  8.7  mm.  (1.454 
X  6) .  The  size  of  the  retinal  image  of  a  standard  letter  of  6  meters  = 
■"■^ooo  of  8.7  =  0.02175  mm.,  and  the  strokes,  or  openings,  being  3^^  the 
size,  have  an  image  of  0.00435  mm.  A  large  number  of  people,  after 
correction  of  their  ametropia,  have  a  visual  acuteness  of  1.25  of  normal, 
and,  therefore,  letters  constructed  on  an  angle  of  4'  have  been  used  for 
testing  visual  acuteness.  The  retinal  images  of  the  strokes  of  such 
letters  are  %  of  0.00435  =  0.00348  mm.  The  size  of  the  cones  of  the 
macular  region  varies  from  0.0033  to  0.0036  mm.,  showing  a  most 
interesting  relation  between  the  limit  of  perception  and  the  anatomic 
structure  of  the  retina. 

ACCOMMODATION 

Mechanism  of  Accommodation. — Inasmuch  as  the  eye  is  inex- 
tensible,  it  cannot  adapt  itself  for  the  perception  of  objects  situated 


36 


GENERAL    OPTICAL    PRINCIPLES 


at  different  dij-tances  by  increasing;  the  length  of  its  axis,  but  only  by 
increasing  the  refractive  power  of  its  lens.  Rays  diverging  from  near 
objects  are  thus  brought  to  a  focus  at  the  same  distance  as  the  rays 
diverging  from  remote  objects.  This  power  the  eye  possesses  of  adapt- 
ing its  refraction  for  different  distances  is  called  accommodation,  and  the 
change  required  in  its  optical  adjustment  is  effected  by  the  ciliary 
muscle  in  the  following  manner:  The  ciliary  muscle,  which  lies  between 
the  sclera  and  the  ciliary  processes,  and  which  is  attached  posteriorly 
to  the  choroid  tract  by  fibers  known  as  the  tensor  choraidea^,  contracts. 
This  contraction  draws  forward  the  choroid  and  ciliary  processes,  to 
which  is  attached  the  suspensory  ligament  of  the  lens  or  zonula  of  Zinn. 
Hence  the  zonula  is  relaxed,  and  the  tension  which  it  has  exerted  on  the 
lens  capsule  is  removed.     The  crystalline  lens,  a  soft  and  elastic  body, 


Fig.  21. — A,  Accommodation  according  to  Helmholtz.     The  dotted  line  representa 

the  thicker  form  assumed  by  the  lens  when  the  traction  of  the  zonula  is  diminished  hy 
the  contraction  of  the  ciliary  muscle.  B,  Accomniodation  accordinj;  to  TschorninK- 
The  unbroken  lines  show  the  lens  at  rest.  The  dotted  lines  show  the  change  occurring 
during  accommodation,  supposed  to  be  due  to  the  traction  of  the  zonula  being  increased 
by  the  contraction  of  the  ciliary  muscle  (Cutler). 

thus  freed  from  compression,  tends  to  assume  a  spheric  shajM',  bulges 
forward,  and  becomes  more  convex.  It  has,  in  effect,  added  to  its  ante- 
rior surface  another  convex  lens.  As  the  ciliary  muscle  contracts  more 
vigorously,  tiiis  added  convex  lens  becomes  stronger.  This  is  the 
Helmholtz  theory,  and  attempts  to  disprove  it  liave  not  been  success- 
ful, as  has  been  shown  by  (\  Hess. 

Tscherning  holds  a  different  view  of  the  nHMJiaiiisin  of  atconnno- 
dation,  thus  expressed  by  Colman  Ward  Cutler:  Accommodation  does 
not  depend  on  a  relaxation  of  the  zonida  of  Ziini,  but  on  its  tension 
through  the  agency  of  the  ciliary  nuiscle,  whereby  the  peripiieral 
portion  of  the  lens  is  flatt(Mied  anil  tiie  curve  of  the  anterior  surface, 
from  an  approximately  spheric,  approaches  a  hyjxMboloid  form. 
Investigations  indicate  that  this  theory,  thus  briefly  sunuii.-iri/.ed, 
is  not  corre<-t  and  that  the  explanation  of  the  mechanisni  of  ;u'commo- 


EXERCISE    OF   THE    POWER   OF   ACCOMMODATION  37 

dation  given  by  Helmholtz  should  be  retained,  even  though,  as  Duane 
points  out,  the  Helmholtz  theoiy  does  not  elucidate  all  the  phenomena 
of  presbj'opia. 

Karl  Grossmann  while  investigating  a  case  of  congenital  aniridia 
noted  the  following  changes  during  accommodation:  The  diameter 
of  the  lens  equator  became  smaller;  the  anteroposterior  diameter  of 
the  lens  increased;  the  anterior  pole  of  the  lens  moved  forward,  and  its 
posterior  pole  backward;  both  the  anterior  and  posterior  surfaces  of 
the  lens  formed  a  lenticonus;  the  lens  in  toto  moved  upward  and  inward. 

Exercise  of  the  Power  of  Accommodation. — If  an  emmetropic 
individual  wishes  to  see  an  object  situated,  for  example,  25  cm.  distant, 
he  must  increase  his  accommodative  power  to  such  a  degree  that  in 
effect  he  adds  to  his  crystalhne  lens  another  lens  of  4  diopters — i.  e., 
one  having  a  focal  length  of  25  cm.  Rays  diverging  from  25  cm.  are 
thus  given  a  parallel  direction  and  are  brought  to  a  focus  on  the  retina 
by  the  original  refractive  power  of  the  eye. 


Fig.  22. — Increased  convexity  of  the  lens  diiring  accommodation.  The  solid  white 
outline  of  the  lens,  Z, shows  its  form  when  relaxed.  The  dotted  line  shows  the  increased 
curvature  of  the  anterior  surface  during  accommodation,  and  its  advancement  forward 
into  the  anterior  chamber,  a.  Z  is  the  suspensorj^  ligament ;  m,  the  ciliary  muscle;  and  i, 
the  iris  (Landolt). 

The  degree  of  accommodation  varies  according  to  the  distance  of 
the  object;  it  is  not  possible  for  an  eye  to  be  adapted  for  two  different 
distances  at  one  time.  By  means  of  the  accommodation  the  eye  is 
adjusted  for  all  distances  between  its  farthest  and  nearest  point  of 
distinct  vision. 

The  far  point  of  an  eye,  punctum  remotum,  is  the  point  from  which 
come  rays  having  the  least  divergence,  or  toward  which  go  rays  having 
the  greatest  convergence  that  allows  their  focusing  on  the  retina. 
From  this  point  rays  are  focused  on  the  retina  with  the  ciHary  muscle 
entireh'  relaxed,  the  refraction  of  the  eye  being  at  its  minimum,  R. 
This  point,  or  its  distance  from  the  eye,  is  designated  r. 

The  near  point  of  an  eye,  punctum  proximum,  or  p,  is  the  point 
from  which  come  the  most  divergent  rays  that  can  be  focused  on  the 
retina.     These  are  focused  with  the  ciliary  muscle  contracted  to  its 


38  GENERAL    OPTICAL    PRINCIPLES 

fullest  extent,  and  the  eye  in  its  condition  of  the  maximum  refraction, 
expressed  by  P.  The  space  lyinj;  between  r  and  p  is  called  the  region 
of  accommodation. 

The  range  of  accommodation,  likewise  denominated  the  power 
or  amplitude  of  (urontmudotion.  is  the  difference  between  the  refractive 
power  of  the  eye  acconmiodated  for  its  far  point  and  accommodated  for 
its  near  point.     This  is  expressed  by  A.     A  =  P  —  R. 

As  the  refractive  power  is  the  inverse  of  the  focal  distance,  ihe 
refractive  power  of  the  eye,  when  accommodated  for  its  far  point  r.  is 

R  =     .     If  we  express  the  value  of  r  in  meters,  we  shall  then  have  the 
r 

refractive  power  of  the  eye  expressed  in  diopters,  a  diopter  beinj:  a  lens 
of  1  meter  focus.     If  r  =  1  meter,  R  =       =1  diopter  =  1  D.     If  r  is 

infinitely  distant,  R       =  0. 

CD 

In  the  same  manner      =  P,  the  refractive  power  of  the  eve  when 

V  .  ^ 

accommodated  for  its  nearest  point.     If  we  obtain  the  value  of  p  in 

centimeters  and  wish  to  know  how  many  diopters  it  equals,  we  must 

divide  100  by  the  number  of  centimeters  equal  to  p.     Let  P  =  10  cm., 

then  P  =  =  10  D.     If  p  is  expressed  in  fractions  of  a  meter,  we 

obtain  the  same  result:  by  dividing  1  l)y  the  value  of  />,  in  meters.  10 

cm.  =         of  a  meter.     P  =      -    =   10   D,   or,   in   decimals,    1    -i-   0.1 

meter  =  10  D — that  is,  in  order  to  focus  ray.,  from  10  cm.,  we  require 
10  times  as  much  accommodation  as  is  necessary  to  focus  rays  from  1 
meter,  and  since  an  eye  adapted  to  a  distance  of  1  meter  exerts  1 
diopter  of  accommodation  at  a  distance  of  Ho  meter,  or  10  cm.,  it 
must  exert  10  diopters  of  accommodation. 

To  find  the  range  of  accommodation  we  must  first  ilctiTiniiie  the 
far  point.  This  is  accomplished  by  means  of  test-letters  held  in  front 
of  the  patient.  If  the  patient  has  maximum  acuteness  of  distant  vis- 
ion, r  is  infinite  [when  R  =         =  O]  or  negative.     If  vision  is  less  than 

CO 

nornud  at  (i  meters,  but  is  nornuil  at  1.5  meters,  r  =  In  meters;  R  then 

=  ,   _  =  0.()()  D.     If  distant  vision  becomes  or  remains  distinct  wluMi  a 
l.o 

convex  gla.ss  of  2  I )  is  placed  beft)re  the  eye,  then  R  =  —  2  I);  that  is,  the 

far  i)()int.  of  such  an  eye  is  negative,  a  point  behind  the  retina  toward 

which  rays  conveige.     This  condition  is  further  discussed  oji  page  120. 

The  near  point  is  usually  found  l»y  gradually  approaching  a  card 

cont.aining  fine  print  until  the  nearest  point  from  the  eye  at  which  it 

still  remains  distinct  is  reached.     The  tlistance  of  this  point  from  the 

anterior  surface  of  the  cornea,  is  mea.sure(l.     I'or  this  purpose  large 

print  may  be  rtNluced  by  ])li(»t(ilith(igraphing,  so  as  to  subttnid  the 


RANGE    OF    ACCOMMODATION  39 

standard  angle  of  5'  at  a  distance  of  25  cm.  or  less,  and  is  usually 
arranged  on  suitabl}^  shaped  cards.  According  to  Duane,  the  best 
test  object  for  practical  purposes  is  a  simple  engraved  line  0.2  mm, 
thick  and  3  mm.  long,  which,  when  brought  within  the  near  point,  blurs 
slightly  and  then  doubles.  In  making  his  estimates  he  prefers  to 
reckon  from  the  anterior  focus  of  the  eye — i.  e.,  from  a  point  13  mm. 
in  front  of  the  cornea. 

The  formula  f 07'  obtaining  the  range  of  accommodation  is  ^  =  P  —  K,- 

If  p  is  at  20  cm.,  P  =  ^^  =  5  D,  and  r  is  at  infinity,  R  =  0,  then 

A  =  P  =  5  T).     This  is  the  case  in  emmetropia. 

If  p  is  at  10  cm.,  P  =  — ^  =  10  D,  and  r  is  at  25  cm.,  R  =  — —  = 
10  25 

4  D,  then  A  =  lOD  —  4D  =  6D.     This  is  the  case  in  myopia  of  4  D. 

P  is  greater  than  A. 

If  p  is  at  50  cm..  P  =  -— -  =  2  D,  and  r  is  negative,  —  25  cm.     R  = 

-^  =-4D.     A=2-(-4)  =  2  +  4  =  6D.     This  is  the  range 

of  accommodation  in  a  hyperope  of  4  D,  and  equals  the  sum  of  P 
and  R.' 

The  near  point  is  closer  to  the  eye  in  young  life,  while  the  lens  is 
soft:  as  age  advances  the  lens  becomes  harder  and  the  near  point  gradu- 
ally recedes  until,  at  about  the  age  of  seventy,  the  near  point  has 
reached  infinity,  and  p  and  r  then  coincide,  and  there  is  no  range  of 
accommodation. 

The  range  of  accommodatio7i  is  nearly  constant  for  the  same  age,  so 
that  if  p  is  nearer  than  it  should  be,  myopia  may  be  suspected,  or  if  it  is 
farther  away  than  the  average,  hyperopia  (Fig.  23).  For  this  purpose 
the  table  given  below  is  often  used,  which  records  the  average  of  P  in 
diopters  and  p  in  centimeters  for  the  different  ages.  (Compare  with 
Fig.  23.) 

Table  of  the  Range  of  Accommodation 

10  years 14        diopters  p  =      7      cm. 

15  years 12  ' '  p  =      8.3 

20  vears 10  "  p  =     10 

25  years 8.5  "  p  =     12 

30  years 7  "  p  =     14 

35  years 5.5  "  p  =    IS 

40  years 4.5  "  p  =    22 

-15  years 3.5  ".  p  =    28 

50  years 2.5  "  p  =    40 

55  years 1 .  75       ' '  p  =    55 

60  years 1  "  p  =  100 

65  years 0 .  75  "  p  =  133 

70  years 0.25  "  p  =  400 

75  years 0  "  p  =    ca 

^  p  refers  to  the  distance  of  the  near  point  in  centimeters.  P  refers  to  the  re- 
fractive power  of  the  ej'e  in  accommodation  for  p.  r  refers  to  the  distance  of  the 
far  point.     R  refers  to  the  refraction  of  the  eye  when  accommodated  for  r. 


40 


GENERAL   OPTICAL   PRINCIPLES 


Duane  and  J.  B.  Thomas,  in  an  attempt  to  determine  the  normal 
range  of  accommodation,  have  reached  conchisions  somewhat  at 
variance  with  those  of  Dontlers,  which  are  usually  recorded.  The 
accommodation  in  childhood  and  youth  they  found  to  be  not  so  high 
as  he  states.     The  accommodation  does  not  decrease  year  after  year 


Age    „^10     15      20      2r.     30     35      40     45     50     S5      60     65      70 


20 
19 
18 
17 
16 
15 
14 
13 

O  12 

S' 
"2.  11 

S    10 

9 

8 

7 

6 

5 

4 

3 

2 

1 


— \- 

, 

\ 

N^. 

\ 

\ 

\ 

\ 

i 

^ 

\ 

V 

\ 

\ 

IS 

\ 

\'\ 

\ 

\ 

\ 

IS 

1    's 

nJ      ^> 

\ 

1 

•■vj\\ 

1 

I^M_ 

\\\ 

\\\ 

'^\^x 

'•CVsl"1- — 

— 

1 

1 

Pi  t  7  ■ 

53 

56 

59 

62 

6*7 

71 

7*7 

8*3 

9 

10 

U 

125 

14 

17 

20 

25 

33 

SO 

100 

oo 


Fig.  23. — Range  of  accommodation  at  different  ages.  The  numbers  on  the  left  hand 
give  the  strength  of  the  lens,  which  placed  before  the  emmetropic  eye  at  a  distance  of 
1.3  mm.  from  the  apex  of  the  cornea  (t.  e.,  placed  at  the  anterior  focus  of  the  eye),  can  re- 
place the  accommodation  of  the  eye  at  the  given  age,  and  hence  is  equivalent  to  the  ac- 
commodation, so  far  as  regards  the  increase  of  refractivity  in  the  eye  which  the  latter 
produces.  These  numbers,  therefore,  give  the  range  of  accommodation  of  the  eye.  The 
right-hand  numbers  give  the  focal  distances  of  these  lenses  (in  centimeters).  The  dis- 
tance of  the  near  point  from  the  apex  of  the  cornea  is  found  by  adding  to  the  focal 
strength  of  the  lens  its  distance  from  the  cornea  (i.  »..  1,'i  mm.).  Obviously,  no  single 
observer  can  follow  the  progress  of  the  range  of  accommodation  from  youth  to  age  in 
one  and  the  same  individual.  The  progress  of  accommodation  can,  therefore,  be  found 
only  by  determining  it  in  a  large  number  of  persons  with  normal  eyes  at  difTerent  ages, 
and  taking  the  mean  of  the  observations.  This  is  shown  by  the  contiinious  line,  whiclj 
indicates  the  mean  position  of  the  near  point  (without  reckoning  in  the  13  mm.)  of  an 
emmetropic  eye  at  different  ages.  The  upper  and  lower  dotted  lines  give  the  least  and 
the  greatest  distance  of  the  near  i)i)int  that  has  been  found  in  the  individual  cases. 
They  accordingly'  show  the  limits  within  which  the  position  of  the  near  point  can  still 
be  regarded  as  normal.  The  ring  denotes  the  limit  of  presbyopia  as  conventionally  set. 
(After  Donders,  amended  and  described  by  Duane.) 


by  any  steady  sweep,  inasmuch  as  il  may  remain  unchanged  for  years 
at  some  periods  of  life.  After  tifty-on(>  the  acctimmodation  remains 
nearly  constant,  diminishing  only  0.50  I)  in  ten  years.  Duane's  re- 
searches are  calciilalecl  to  fix  not  only  the  mean  range  of  accommoda- 
tion, but  also  the  upper  ;in(l  lower  limits  al  eaeii  ag»'. 


ANGLE  gamma:  ANGLE  ALPHA  41 

Abnormal  Accommodation. — Failure  of  accommodation  due  to 
age  is  termed  presbyopia  (^see  page  157).  The  chief  anomahes  of 
accommodation,  adopting  and  quoting  Duane's  classification,  are 
insufficiency  of  accommodation  (see  also  page  128),  in  which  the 
accommodation  is  constantl}''  below  the  lower  limit;  ill-sustained 
accommodation,  in  which  accommodation  is  normal  in  amount,  but 
soon  gives  out;  inertia  of  accommodation,  in  which  difficulty  in  chang- 
ing from  one  accommodative  state  to  the  other  is  experienced; 
inequality  of  accommodation  (see  also  page  159),  in  which  the  accom- 
modation in  the  two  eyes  is  not  the  same;  and  excessive  accommoda- 
tion in  which  the  accommodation  is  persistently  above  the  normal  limit. 

Insufficiency  of  accommodation,  according  to  Duane,  usually 
occurs,  and  it  is  not  infrequent  between  the  ages  of  eighteen  and  forty- 
five.  Theoreticallj',  it  is  due  to  undue  rigidity  of  the  lens  or  weakness 
of  the  ciliary  muscle,  and  may  be  associated  with  an  undue  effort  of 
convergence,  that  is,  convergence  excess  (see  page  610),  but  also  and 
more  frequently  with  convergence  insufficiency  (see  page  611).  The 
main  SN'mptom  is  asthenopia,  and  prominent  causes  are  various  tox- 
emias due  to  tuberculosis,  intestinal  disorders,  nasopharyngeal,  tonsil- 
lar, and  dental  disease,  hypopituitarism,  neurasthenia,  overwork, 
eye  strain,  and  vascular  hypertension.  In  the  author's  experience 
early  arteriosclerosis  is  a  common  cause  of  this  condition.  Evidently 
the  remedies  are  removal  of  the  cause,  suitable  correcting  glasses,  with 
an  addition  for  reading  to  correct  the  unnatural  presbyopia,  and,  in 
the  author's  experience,  the  instillation  of  a  weak  eserin  or  pilocarpin 
solution  (of  eserin  sahcylate  gr.  Mo-f5i  (0.0015  gm.-30  c.c);  of 
pilocarpin  hydrochlorid,  gr.  3^^o  f5i  (0.003  gm.-30  c.c).  Unequal 
accommodation,  when  non-pathologic  in  origin,  ma}'  give  rise  to  much 
discomfort,  especially  when  the  presbyopic  age  is  approached  or 
reached,  and  must  be  recognized  in  the  correcting  glasses  (see  also 
page  159). 

Angle  Gamma :  Angle  Alpha. — The  eye,  in  looking  at  any  object, 
is  directed  forward  in  such  a  manner  that  the  image  is  formed  on  the 
macida  lutea.  The  eye  is  now  said  to  ''fix"  or  fixate  the  object.  A 
line  drawn  from  the  object  thus  fixed  to  the  macula  lutea  is  called  the 
visual  line,  or  visual  axis. 

The  point  about  which  the  eye  revolves,  in  order  to  be  brought 
into  this  position,  is  called  the  center  of  rotation,  and  has  its  position 
14  mm.  back  of  cornea.  The  line  which  connects  the  object  with  the 
center  of  rotation  is  designated  the  line  of  fixation. 

The  optic  axis  is  an  imaginary  Hne  passing  through  the  center  of  the 
cornea  and  lens  and  the  point  of  rotation  to  the  posterior  pole  of  the 
eye — i.  e.,  a  point  usually  between  the  macula  and  optic  papilla. 

If  the  macula  lutea  coincided  with  the  posterior  extremity  of  the 
optic  axis,  the  visual  line,  line  of  fixation,  and  optic  axis  would  also 
coincide.  Generally,  this  coincidence  does  not  exist.  In  emmetropia 
and  hyperopia  the  optic  axis  passes  to  the  inner  side  of  the  macula 
lutea,  and  the  visual  line  and  line  of  fixation  then  form  angles  with 
the  optic  axis.     In  Fig.  24  A-A'  is  the  optic  axis  passing  through  the 


42 


GENERAL    OPTICAL    PRINCII'LES 


center  of  the  eornea,  C,  the  ncxhil  points  of  the  eye,  K'-K",  and  the 
center  of  rotation,  M.  0-F  is  the  visual  Hue  conneeting  the  object,  0, 
with  the  fovea,  F.  0-M  is  the  hne  of  fixation,  drawn  from  0  to  the 
center  of  rotation,  M.  The  eye,  in  order  to  fix  0,  has  its  optic  axis, 
A-A',  deviated  outward.  The  angle  formed  by  the  line  of  fixation, 
0-M,  with  the  optic  axis  A-A',  is  called  the  angle  gamma,  y,  or  the 


Fio.  24. — Aimlc  ulplia  and  aiij^lc  Kiiiiiina:  .1  .1'.  (*|i|ic  a\'s;  <)  /■'.  \isiinl  line:  (i-M. 
line  of  fixation;  A'  L,  major  axis  of  corneal  ellipse.  'I'lie  line  of  fixation  does  not  corre- 
spond with  the  f)pti(r  axis,  hut  forms  the  annle  (>M  A^  annle  lamina  nearly  etiual  to 
the  angle  0-A'-/l,  formed  hy  the  visual  line  with  the  optjc  axis.  O-X-A  may  be  con 
sidered  as  the  angle  gamma.  The  visual  line  does  not  pads  througli  the  summit  of  the 
corneal  curve,  H,  hut  forms  with  the  axis  df  the  cornea,  /i  /..  the  angle  (>  .Y  h'.  the 
angle  alpha  (Landolt). 

angle  formed  \)y  the  visunl  line  with  the  npiic  ;i\is  m;iy  b(>  coiisiilered 
as  the  angle  gaimna. 

The  Hignificaiicc  »if  lliis  angle  is  that  a  pt'isdu.  while  really  fixini,^ 
an  object,  seems  (o  lia\c  a  divergeiuc  of  the  visual  liii(>s  (iiviM'geiit 
squint.     In  estimating  thf  dcgicc  (d"  a  (liNcrgciit  str.altisnuis  it  is  iieces 


\ 


CON\^ERGENCE  43 

sary  to  consider  the  value  of  this  angle.  The  amount  of  the  angle 
gamma  is  usually  5°,  but  it  maj^  reach  as  much  as  10°.  When  the  ante- 
rior extremity  of  the  visual  line  passes  to  the  inner  side  of  the  optic 
axis,  the  angle  gamma  is  positive,  or  +;  this  is  the  usual  condition 
in  emmetropia  and  hyperopia.  The  convergence  of  the  visual  line 
exceeds  the  convergence  of  the  optic  axis  b}'  the  amount  of  this  angle. 
When  the  visual  hne  coincides  with  the  optic  axis,  there  is  no  angle 
gamma.  The  visual  line  in  high  myopia  sometimes  passes  to  the  outer 
side  of  the  optic  axis.  The  eyeball  must  then  be  deviated  inward  in 
order  to  fix  on  the  object.  This  produces  the  effect  of  a  convergent 
squint.  It  must  be  distinguished  from  squint,  and  if  convergent 
strabismus  also  exists,  the  value  of  this  angle  must  be  deducted  from 
the  apparent  squint.  In  this  latter  form  of  the  angle  gamma,  where 
the  anterior  extremity  of  the  visual  line  passes  to  the  outside  of  the 
optic  axis,  the  angle  is  negative,  or  — .  The  convergence  of  the  visual 
line  is  less  than  the  convergence  of  the  optic  axis,  the  angle  is  nega- 
tive, or  — .  The  convergence  of  the  visual  line  is  less  than  the  con- 
vergence of  the  optic  axis  by  the  amount  of  this  angle. 

The  amount  of  this  angle  may  be  measured  by  placing  the  patient 
before  the  perimeter  as  if  his  field  were  to  be  taken  (see  page  601). 
The  e3^e  is  fixed  on  the  central  point,  and  a  lighted  candle  is  moved 
along  the  arc  in  a  horizontal  direction  until  its  reflection  is  obtained 
from  the  portion  of  the  cornea  corresponding  to  the  center  of  the  pupil. 
The  position  of  the  candle  may  now  be  read  from  the  arc  in  degrees, 
and  represents  the  size  of  the  angle  gamma. 

The  apex  of  the  cornea  does  not  generally  coincide  with  the  center 
of  the  cornea,  but  is  displaced  laterally.  The  major  axis  of  the  corneal 
ellipse,  represented  in  the  figure  by  E-L,  therefore  forms  an  angle  with 
the  visual  line.  The  angle  alpha  is  the  angle  formed  by  the  visual  line 
with  the  major  axis  of  the  corneal  ellipse.  It  is  positive  when  the  major 
axis  of  the  cornea  passes  to  the  outer  side  of  the  visual  line;  if  the 
corneal  axis  passes  to  the  inner  side  of  the  visual  line,  the  angle  alpha  is 
negative.  In  the  figure  the  angle  0-X~A  is  the  angle  gamma;  the  angle 
0-X-E  is  the  angle  alpha. 

From  what  has  been  said  it  will  be  seen  that  the  visual  line  is  a 
secondarj'  axis  to  the  optical  system  of  the  eye.  The  obhque  position 
of  the  refracting  surfaces  to  the  visual  line  may  be  the  cause  of  an  in- 
creased refraction  in  the  horizontal  meridian  constituting  astigmatism. 

CONVERGENCE 

In  the  visual  act  of  one  eye  the  sensation  conveyed  to  the  brain  is 
projected  outward  over  the  same  course  by  which  it  arrived — that  is, 
the  object  is  referred  to  a  position  in  the  field  of  vision  which  it  actually 
occupies.  If  the  projection  outward  of  the  images  of  the  two  eyes  is 
such  that  they  overlie  each  other,  the  person  will  have  single  vision; 
if,  however,  they  are  projected  in  different  positions,  double  vision  is 
the  result. 

The  images  are  projected  in  different  positions  when  they  are  not 


44 


GENERAL   OPTICAL   PRINCIPLES 


formed  on  identical  points  of  the  two  retinas.     The  fovea  centralis  being 
the  most  sensitive  portion  of  the  retina,  the  eye  is  naturally  so  directed 

toward  an  object  that  the  image  is  formed 

upon  it.  The  eye  is  then  said  to  fix  the  object. 
The  foveae  of  the  two  eyes  arc  identical  points, 
and  images  formed  on  them  are  projected  out- 
ward so  as  to  overhe  or  fuse  into  each  other; 
points  at  a  corresponding  distance  to  the  right 
of  each  fovea,  or  to  the  left,  or  upward  or 
downward,  are  also  identical,  and  images 
formed  on  them  produce  but  a  single  im- 
pression. Objects  in  the  field  of  vision  to  the 
right  of  the  point  of  fixation  form  a  retinal 
image  to  the  left  of  the  fovea.  Objects  to  the 
left  of  the  point  of  fixation  form  an  image  to 
the  right  of  the  fovea  (see  Figs.  246,  247).  All 
images  formed  on  the  retina  to  the  right  of 
the  fovea  are  projected  out\yard  to  the  left. 
Those  formed  on  the  left  of  the  fovea  are  pro- 
jected to  the  right;  in  the  same  way  those 
formed  on  the  upper  part  of  the  retina  are 
projected  downward,  and  those  formed  on  the 
lower  part  of  the  retina  are  projected  upward. 
The  eyeballs  are  separated  laterally,  on  the 
average,  64  mm.  in  adult  eyes.  In  looking  at 
a  distant  object,  if  the  axes  of  the  eye  are 
parallel,  the  images  are  formed  on  corre- 
sponding points  of  the  retinas,  but  when  the 
object  is  at  some  nearer  point,  the  ejes  must 
be  turned  inward  in  fixating  the  object,  to  com- 
pensate for  their  lateral  separation.  This 
function  of  the  eyes  is  termed  convergence. 

The  ej^eliall  is  rotated  inwartl  by  the 
internal  rectus  muscle,  so  that  its  visual  fine 
is  directed  toward  the  object.  This  function 
is  very  closely  associated  with  that  of  accom- 
modation: one  cannot  act  in  any  very  great 
degree  without  the  other  also  coming  into 
play.  The  movement  inwartl  of  the  eye  is 
measured  by  the  angular  deviation  of  the  visual  line,  termed  the  angle 
of  convergence. 

The  unit  of  convergence  is  the  angle  through  which  the  visual 
axis  moves  to  fix  on  a  point  1  meter  tlistant.  This  is  termed  l-nieter 
angle  of  convergence  (Nagel;  l"'ig.  25).  If  the  object  fi.xed  is  only  Y^ 
meter  chstant,  the  movement  will  l)e  twice  as  great;  it  is  then  2-meter 
angles.  A  point  at  '3  nu'ter  would  recjuire  H-meter  angles,  and  so 
on;  10-meter  angles  of  convergence  mean  that  the  eye  is  directed  to  a 
point  only  Mq  meter  distant. 


0    "  M 


Fig.    I'o.     MuU:r    annles    of 
convergence  (Landolt). 


METER    ANGLE  45 

Meter  Angle. — In  the  figure,  O  and  0'  represent  the  centers  of  rotation  of  the 
two  eyes;  0-0'  is  the  distance  between  these  points,  termed  the  interocular  dis- 
tance. It  is  measured  by  the  distance  between  the  pupils  during  fixation  for  re- 
mote objects.     0-M  is  one-half  this  distance. 

The  line  C-M  is  perpendicular  to  0-0'.  ^Mien  the  object  is  situated  on  the 
line  C-M,  the  convergence  of  each  eye  is  equal.  WTien  the  visual  lines  J-0  and 
J'-O'  are  parallel,  the  angle  of  convergence  is  nil;  when,  however,  the  visual  Unes 
are  directed  to  C",  1  meter  distant,  O-J  has  deviated  to  O-C  J-O-C  is  the  angle 
through  which  the  visual  line  has  moved  to  fix  on  C.  This  is  1-meter  angle  of 
convergence. 

C-M  being  parallel  to  J-0,  O-C'-M  is  equal  to  J-O-C. 

In  the  right-angled  triangle  O-C'-M,  0-M  equals  one-half  the  interocular 
distance. 

O-C  =  the  distance  of  the  point  of  fixation. 

0-M 

f^pf  =  the  sme  of  the  angle  O-C'-M. 

The  average  interocular  distance  is  64  mm.  0-M  =  Vi  of  64,  or  32  mm.  O-C 
is  1  meter  distant. 

--— -,  = =  .032  =the  sine  of  1-meter  angle.     This  corresponds  to  1°  50'. 

O-C       1000  ° 

If  the  eye  is  directed  to  a  point  /2  meter  distant,  C",  the  visual  line  will  deviate 
twice  as  much — that  is,  it  deviates  32  mm.  at  }-i  meter  distance.  If  the  point  of 
fixation  is  only  Ho  meter  distant,  the  amount  of  convergence  will  equal  10-meter 
angles. 

To  find  the  value  of  this  in  degrees  we  employ  the  same  formula  as  above : 

O-M 
-— ^   =  sine  of  angle  O-C^'^-M.     0-M  =  32.     O-C^'^  =  Ho  meter  =  100  mm. 

32 
-— =  0.32,  the  sine  of  angle  of  convergence  =  18°  40'. 

The  value  of  the  meter  angles  in  degrees  is  obtained  very  nearly  by  multipljang 
1°  50'  b}'-  the  number  of  meter  angles.  The  value  of  the  meter  angle  varies  with 
the  interocular  distance,  and  as  there  is  considerable  difference  in  this  distance,  a 
separate  calculation  is  necessary  for  each  individual. 

A  more  simple  method  of  determining  the  value  of  the  meter  angle 
is  to  find  its  relation  to  the  centrad.  The  centrad  is  a  prism  which 
deviates  a  ray  the  Moo  part  of  the  radius,  measured  on  the  arc  (see 
page  19).  The  deviation  of  the  meter  angle  is  measured  on  the  sine. 
For  the  angles  obtained,  the  sine  and  arc  are  almost  equal. 

One-meter  angle  equals  a  deviation  of  32  mm.  (the  average  distance 
between  the  centers  of  rotation  of  the  ej'es  being  64  mm.)  at  1  meter 
distance  =  32  in  1000  mm.,  or  3.2  in  100  =  3.2  centrads.  One  centrad 
=  0.57295°;  3.2  centrads  =  1°  50'.  Ten-meter  angles  equal  a  devia- 
tion of  32  mm.  in  Ko  meter,  100  mm.,  32  in  100,  or  32  centrads  = 
18°  20'.  A  32-centrad  prism  not  only  gives  us  the  value  of  10-meter 
angles  of  convergence,  but,  placed  before  the  eye  with  the  base  inward, 
it  takes  the  place  of  10-meter  angles  of  convergence,  so  that  the  eye, 
without  any  convergence,  would  see  an  object  on  the  line  C-M 
10  cm.  distant,  as  if  it  were  situated  at  a  remote  distance. 

The  convergence  becomes  greater  as  the  point  of  fixation  approaches 
nearer.  The  number  of  meter  angles  is,  therefore,  inversely'  propor- 
tional to  the  distance  expressed  in  meters.  We  thus  designate  the 
convergence  in  terms  which  indicate  the  same  number  of  units  of  con- 
vergence as  the  diopters  of  accommodation  necessary  for  the  same  dis- 


46  GENERAL   OPTICAL   PlilNCIPLES 

tance.    An  emmetrope,  in  looking  at  an  object  0.25  meter  distant,  would 
employ  4-inotf'r  :in.<;les  of  coiivcrgonce  and  4  diopters  of  accommodation. 

The  amplitude  of  convergence  is  the  number  of  meter  angles  of 
convergence  which  the  eyes  can  call  into  action.  It  is  measured  from 
the  far  point  of  convergence  to  the  near  point  of  convergence. 

The  far  point  of  convergence  is  the  point  to  which  the  visual  lines 
are  directed  when  the  convergence  is  relaxed  to  its  utmost;  the  near 
point  of  convergence  is  the  point  to  which  the  visual  lines  are  directed 
when  the  convergence  is  at  its  maximum.  If  in  the  minimum  degree  of 
convergence  the  visual  lines  are  parallel,  the  far  point  of  convergence 
will  be  at  an  infinite  distance.  Usually  the  visual  lines  actually  diverge 
forward  at  the  minimum  of  convergence,  constituting  an  outward 
squint,  and  converge  by  their  posterior  extremities  toward  a  point 
behind  the  eyes.  When  this  is  the  case,  the  far  point  and  a  portion  of 
the  amplitude  of  convergence  are  negative.  In  some  cases,  with  the 
convergence  relaxed  to  its  fullest  extent,  the  visual  lines  still  deviate 
inward,  constituting  an  internal  squint.  The  convergence  in  such  a 
case  will  be  entirely  positive. 

Relation  between  Accommodation  and  Convergence :  Rela= 
tive  Accommodation. — While  the  two  functions  of  convergence  and 
accommodation,  as  has  l)een  previously  explainetl.  are  closely  a.^^so- 
ciated,  there  is  still  some  independence  of  action.  In  other  words,  it 
is  possible  to  accommodate  several  diopters  without  convergence  and 
to  converge  several  meter-angles  without  accommodation.  If  the 
visual  axes  converge  to  a  given  point,  the  accommodation  may  be 
increased  to  a  certain  limit.  The  increased  amount  of  accommoilation 
exercised  in  these  circumstances  is  measured  by  the  ability  to  over- 
come concave  glasses  while  the  object  still  remains  distinctly  in  view, 
and  is  denominated  the  positive  part  of  the  relative  accommodalion. 
It  is  also  possible,  while  the  visual  lines  converge  for  a  given  near  point, 
to  relax  the  accommodation  from  its  association  with  that  degree  of 
convergence  by  placing  convex  glasses  before  the  eyes,  the  object  still 
remaining  distinctly  in  view.  This  relatively  diminished  amount  of 
accommodation  is  called  the  negative  part  of  the  relative  accomtnodation. 
That  convergence;  may  be  altered  while  the  same  effort  of  accommoda- 
tion is  maintained  is  demonstrable  by  placing  a  prism  with  its  base 
inward  before  one  eye,  which  then  rotates  outward,  in  order  that  the 
objeet  may  l)e  seen  singly,  this  object  at  the  same  time  being  perfectly 
distinct.  Kvidcntly  the  same  effort  of  acconunodation  has  been 
maintained,  although  the  convergence  of  the  visual  axes  is  altered. 
At  the  far  point  of  acconunodation  and  convergiMJce  the  acconunoda- 
tion has  somewhat  more  play;  at  the  near  point,  however,  convergence 
has  nuich  the  larger  movement.  Tlie  amplitude  of  conveigence  does 
not  always  diminish  with  age,  as  (Iocs  the  accommodation.  Some 
persons,  however,  have  a  diminished  convergence  powiM'  or  endurance, 
owing  to  changes  in  the  ocular  musch's  similar  in  kiml,  though  less  in 
degree,  to  the  senile  chang(\s  which  usually  occur  in  other  parts  of  the 
nuiscular  syst<'m.  Lucien  Howe  has  designed  an  :ipparatus  for  the 
clinical  measurement  of  the  relative  acconuno(lati»)n  at  the  near  point 


CHAPTER  II 

EXAMINATION  OF  THE  PATIENT  AND  EXTERNAL  EXAMINA- 
TION OF  THE  EYE;  FUNCTIONAL  TESTING 

A  SYSTEMATIC  examination  of  each  patient  should  be  made  in 
order  to  secure  the  preservation  of  careful  records.  For  this  purpose 
the  following  order  of  examination  may  be  used : 

Name  and  residence. 

Age,  sex,  race,  married,  single,  or  widowed. 

Family  history:  hereditary  tendencies;  general  and  ocular  health  of  parents, 
brothers,  sisters,  etc. 

Personal  history:  children,  their  general  and  ocular  health;  pregnancies,  mis- 
carriages; menopause;  former  illnesses;  syphilis;  gonorrhea;  tuberculosis;  injuries. 

Occupation:  relation  of  work  to  present  indisposition. 

Habits:  brain  use;  tobacco;  alcohol;  tea  and  coffee;  narcotics;  sexual. 

Date  and  mode  of  onset  and  supposed  cause  of  present  trouble;  outline  of  its 
course. 

Organs  of  digestion:  teeth;  mouth;  tongue;  tonsils;  stomach;  intestines. 

Organs  of  respiration:  nose;  accessory  sinuses;  throat;  lungs. 

Organs  of  circulation:  heart;  pulse;  blood. 

Kidneys:  examination  of  urine. 

Abdominal  organs:  liver;  spleen. 

Organs  of  generation;  menses;  leukorrhea;  uterine  disease;  urethral  and  seminal 
vesicle  and  prostatic  disease. 

The  skin,  previous  and  present  diseases.     Endocrine  organs: 

Wassermann  test  of  the  blood  and  spinal  fluid  and  tests  for  tuberculosis:  fixa- 
tion-complement test  for  gonorrhea. 

Metabolic  analysis. 

Nervous  system;  inteUigence;  evidences  of  hysteria  and  psychasthenia;  hallu- 
cinations; sleep;  vertigo;  gait;  station;  tendon-  and  muscle-jerks;  paralysis;  tremor; 
pain;  subjective  sensations;  convulsions;  headaches  and  their  position. 

Eyes:  previous  attacks  of  inflammation;  injuries;  infections;  ocular  palsy  or 
squint;  amblyopia;  previous  use  of  glasses;  ability  to  use  eyes. 

Direct  inspection  and  examination  of  eyes:  inspection  of  the  skull  and  orbits 
(symmetry  or  asymmetry);  ciliary  borders;  puncta  lacrimaUa;  upper  and  lower 
culdesacs;  conjunctivae;  blood-vessels  of  the  conjunctiva  and  episclera;  caruncles; 
comeae  (obUque  illumination  and  loupe;  corneal  microscope);  irides  (mobility  and 
color);  anterior  chambers  (depth  and  character  of  contents);  vision;  accommoda- 
tion; balance  exterior  eye  muscles;  prism-convergence;  prism-divergence;  sursum- 
vergence;  convergence  near  point;  position  of  eyes;  mobilitj'  of  globe;  tonometer; 
light-sense;  color-sense;  fields  of  vision;  field  of  fixation;  ophthalmoscope;  ophthal- 
mometer; retinoscope;  test-lenses. 

This  schedule  of  examination  must  be  modified  to  suit  individual 
cases,  as  the  patient  presents  trivial  local  lesions  directly  discoverable 
by  inspection,  or  forms  of  disease  requiring  detailed  study  for  their 
proper  interpretation. 

Direct  Inspection  of  the  Eye. — After  the  preliminary  examina- 
tion which  the  patient  demands,  the  surgeon  proceeds  to  the  direct 
inspection  of  the  eye.     The  surface  of  the  lids  should  be  examined  for 

47 


48     EXTERNAL  EXAMINATION  OF  THE  EYE — FUNCTIONAL  TESTING 

swollen  superficial  veins,  a  common  index  of  inflammation  of  the  globe; 
their  edges  for  inflammation,  parasites,  and  misplaced  cilia;  the  puncta 
for  permeability,  pressure  at  the  same  time  being  made  over  the  lacri- 
mal sac  in  order  to  express  from  it  through  the  puncta  any  contained 
fluid;  the  upper  and  the  lower  conjunctival  culdesac  for  accumulated 
secretion,  granulations,  and  foreign  bodies;  the  palpebral  conjunctiva 
for  hardened  secretion  in  glands;  the  caruncles  for  swelling,  attached 
foreign  bodies,  and  irritation  by  incurved  cilia;  and  the  conjunctiva 
for  the  information  to  be  derived  from  its  blood-vessels. 

In  order  to  evert  the  lid,  observe  the  following  rule:  Require  the 
patient  to  turn  the  eye  strongly  downward,  seize  gently  the  central 
ej'elashes  of  the  upper  lid  between  the  index-finger  and  thumb  of  the 
left  hand,  draw  the  lid  downward  and  away  from  the  ball,  place  the 
point  of  the  thumb  of  the  right  hand  above  the  tarsal  cartilage  of  the  lid 


Fig.  26. — Position  of  hands  in  the  act  of  everting  the  eyelid. 

which  is  to  be  everted,  the  remaining  fingers  being  steadied  on  the  brow, 
and,  by  a  quick  movement,  turn  the  edge  of  the  lid  over  the  point  of 
the  thumb,  while  this  is  simultaneously  depressed.  During  tlie  entire 
maneuver  insist  upon  the  downward  direction  of  the  patient's  ej'es; 
otherwise  the  lid  cannot  be  turned  without  undue  force  and  pain.  If 
there  are  no  lashes  on  the  upper  ciliary  margin,  the  lower  lid  should  be 
pushed  beneath  the  edge  of  tlie  upper  in  such  a  manner  that  it  acts  as  a 
wedge  on  which  the  superior  lid  is  everted.  In  this  manner  tlie  lid  can 
be  everted  with  the  fingers  of  one  hand.  Care  should  be  exercised  to 
expose  the  tissues  of  the  upper  culdesac  which  he  beneath  th(>  folded  lid 
by  making  a  second  eversion  of  tliis  folded  lid,  or  by  pushing  the  con- 
cealed fold  into  view  by  means  of  a  probe. 

The  surgeon  should  inspect  the  skin  of  the  face  and  ft)relieael,  ex- 
amine the  orbits  by  palpation,  ascertain  the  action  of  the  orbicularis  by 
causing  the  patient  to  close  his  (\yes  as  if  in  sleep,  and  stud>-  the  length, 
width,  and  symmetry  of  the  pal])ebral  fissures  and  the  condition  of  the 
coinmissinal  angles. 

Blood-vessels  of  the  Conjunctiva. —In  health  only  a  few  con- 
spicuous blood-vessels  are  evitient ;  in  inflanunation  many  more  become 
visible.     The  arleiies  of  the  I'onjtiiict  iva  are  derived  from  the  paljieliral 


BLOOD-VESSELS    OF    THE    CONJUNCTn^\  49 

and  lacrimal  branches  of  the  ophthalmic;  those  of  the  episcleral  tissue 
arise  from  the  anterior  ciliary  branches  of  the  ophthalmic,  while  the 
border  of  the  cornea  is  surrounded  by  a  plexus  of  capillar}'  loops  derived 
from  the  anterior  ciliary  vessels.  This  blood-supply  may  be  con- 
veniently divided,  according  to  the  late  Mr.  Nettleship,  into  three 
systems : 

Syste?n  I. — Posterior  conjunctival  vessels,  whose  congestion  pro- 
duces a  bright  red.  velvety  color,  moving,  on  pressure  of  the  eyelids, 
with  the  shifting  of  the  conjunctiva,  usually  associated  with  mucopuru- 
lent secretion,  and  indicating  conjunctivitis.  Conjunctival  congestion 
is  most  intense  at  the  fornix  and  in  its  neighborhood,  and  decreases  as 
the  corneal  margin  is  approached. 

System  II. — Anterior  ciliary  vessels,  composed  b\  perforating  and 
non-perforating  arteries  and  veins.     The  perforating  arteries,  which 

-    i 


Fig.  27. — Eyelid  everted  for  examination  of  its  under  surface  and  the  upper  part  of 

globe. 

supply  the  sclera,  iris,  and  ciliary  bodies,  are  the  branches  seen  in 
health  entering  about  5  mm.  from  the  corneal  margin,  their  points  of 
entrance,  in  dark-complexioned  people,  often  being  distinctly  tinted. 

The  non-perforating  (episcleral)  branches,  invisible  in  the  normal 
eye,  produce, if  congested,  a  pink  zone  surrounding  the  cornea  ("ciliary 
congestion,"  " circumcorneal  zone"),  not  moving  on  pressure  of  the 
lids  with  the  shifting  of  the  conjunctiva,  unassociated  with  purulent 
discharge,  which  is  one  of  the  indications  of  iritis.  Ciliary  congestion 
is  most  distinct  around  the  corneal  margin  and  lessens  as  the  fornix  is 
approached.  As  Haab  remarks,  the  most  congested  circumcorneal 
zone  is  least  involved  in  pure  conjunctival  congestion. 

The  perforating  veins  and  their  non-perforating  (episcleral)  twigs, 
when  congested,  create  a  zone  of  dusky  hue,  often  a  sj'mptom  of  glau- 
coma, or  appear  in  unequal,  deep-seated  patches  of  hlac  or  violaceous 
color,  indicating  C3^chtis  or  scleritis. 

Systein  III. — Anterior  conjunctival  vessels  and  the  plexus  of  capil- 
laries surrounding  the  cornea,  derived  from  anterior  ciliary  vessels 
through  whose  numerous  small  branches  anastomosis  between  System  I 
and  II  takes  place.     Their  congestion  produces  a  circle  of  bright-red 


50     EXTERNAL  EXAMINATION  OF  THE  EYE  —FUNCTIONAL  TESTING 

injection,  often  partly  on  the  cornea,  a  sign  of  inflammation  of  this 
membrane,  and  typified  in  the  earlj'  vascular  stages  of  interstitial 
keratitis  (see  page  288). 

In  addition  to  these  three  varieties  of  congestion,  numerous  depar- 
tures are  noticeable,  making  it  impo.ssible  to  .separate  the  form  and 
specify  the  individual  system  involved.  In  these  t^'pes  is  found  a 
definite  local  injection,  as  the  leash  of  vessels  passing  to  a  corneal  ulcer; 
or  all  the  systems  are  commingled  in  a  general  inflammation. 

The  blood-vessels  of  the  conjunctiva  can  be  well  observed  with  a 
Zeiss  corneal  microscope.  Luedde  and  Dennis  by  this  means  have 
made  valuable  observations  in  their  studies  of  the  conjunctival  cir- 
culation in  its  relation  to  the  early  signs  of  anteriosclerosis.  Accord- 
ing to  Dennis  the  changes  consist  in  a  clogging  of  the  corpuscles  in 
the  lumen  of  the  vessels;  emptiness  of  the  vessel  in  front  of  the  obstruc- 
tion; beaded  formation  in  the  lumen  of  fine  vessels;  in  advanced 
cases  complete  occlusion  of  vessels. 

Temperature  of  the  Conjunctival  Sac. — According  to  Silex,  the 
temperature  of  the  lower  human  conjunctival  fold  is  35.5o°C.  (95.99°F.) 
— i.  e.,  about  2°C.  lower  than  that  of  the  rectum.  There  is  an  average 
increase  of  0.98°C.  in  inflamed  ej'es,  the  highest  temperature  being 
found  in  acute  iritis.  The  temperature  of  the  cornea  is  about  29°C. 
-84.2°r.  (Leber). 

Inspection  of  the  cornea  reveals  inflammation,  vascularization, 
ulceration,  opacities,  and  foreign  bodies.  Slight  irregularities  are  de- 
tected by  placing  the  patient  before  a  window,  while  the  eyes  are  made 
to  follow  the  uplifted  finger  held  about  1  foot  from  the  face,  and  moved 
in  various  directions.  The  image  of  the  window-bars  reflected  from  the 
cornea  will  be  broken  as  it  crosses  the  spot  of  ineciuaiity. 

A  more  accurate  method  is  to  employ  a  keratoscopc  (Placido's  disk). 
This  instrument  consists  of  a  disk  shaped  like  a  target,  upon  which  are 
drawn  concentric  black  circles,  a  sight-hole  being  in  the  center.  The 
patient  is  placed  with  his  l)ack  to  the  window,  while  the  surgeon  holds 
the  instrument  in  front  of  the  eye,  and,  looking  through  the  central 
aperture,  observes  the  reflections  of  the  circles  from  the  cornea.  If 
these  are  broken  or  distorted,  the  indications  of  irregularity  in  the 
surface  are  present.     (See  also  page  ;U)2.) 

Minute  abrasions  and  ulcers  may  l)e  found  by  dropping  on  the 
ej''e  a  concentrated  alkaline  solution  of  Jiuorcsccin  (.(.Jruebler's  fluor- 
escein, 2  per  cent.;  carbonate  of  soda,  3.5  per  cent.),  which  colors 
green  that  pf)rtion  of  the  cornea  deprived  of  its  epithelium,  or  in 
which  tlie  corneal  epithelium  is  diseased,  while  the  healtiiy  ei)itheliuni 
remains  uiiaiTected.  I'ipitiielium  in  the  immediate  neigiilioriiood  of  a 
corneal  ulcer,  although  appanuitly  not  involved  in  tlu>  pn)i'i>s.s,  will  also 
take  the  stain,  as  pointed  out  by  Benson.  Cocain  solution  instilleil 
|)rior  to  or  after  the  application  of  lluorescein  distinctly  enhjinces  its 
staining  |)roperties,  and  the  epithelium  of  the  cornea,  which  has  bt>en 
softened  by  re|)eated  instillations  of  cocain,  will  t.^ke  on  th(>  fluorescein 
stain.     When  the  lesion  is  not  verv  r<'C(>nt,  or  when  it  is  covered  with 


OBLIQUE    ILLUMINATION  51 

necrotic  tissue,  the  coloration  will  be  yellowish  or  yellowish  green. 
This  substance  also  reveals  defects  of  the  endothelium  of  the  cornea, 
and  E.  von  Hippel  maintains  that  it  produces  a  deep-seated  colora- 
tion of  the  cornea  only  when  the  endothelium  is  absent  or  diseased 
(see  page  361).  C.  A.  Wood  prefers  a  2  per  cent,  solution  of  potassic 
fluorescide  without  the  prehminary  use  of  cocain.  Toluidin-blue,  as 
suggested  bj'  Veasey,  and  eosin  may  hkewise  be  used  as  coloring  agents. 

The  Width  of  the  Cornea. — This  maj-  be  measured  approxi- 
mately by  holding  before  it  a  rule  marked  in  millimeters,  and  noting 
the  number  of  spaces  its  width  occupies,  or  with  Priestley  Smith's 
keratometer,  which  consists  of  a  scale  situated  between  two  planoconvex 
lenses.  The  average  horizontal  diameter  of  the  normal  cornea  is  11.6 
mm.  (Priestley  Smith). 

The  Sensibility  of  the  Cornea. — This  may  be  tested  by  gently 
touching  the  surface  of  this  membrane  with  a  wisp  of  cotton  twisted 
to  a  fine  point.  If  sensation  is  normal,  the  touch  should  be  instantly 
followed  by  the  reflex  act  of  winking  {palpebral  reflex),  although  even 
if  the  cornea  is  insensitive  closure  of  the  hd  may  occur  when  the  test- 
object  comes  into  the  field  of  the  pupil.  This  is  not  due  to  contact, 
but  represents  the  retinal  lid-closure  reflex.  In  organic  anesthesia 
the  lacrimal  reflex  is  wanting,  but  is  present  in  hysteric  anesthesia. 
The  opposite  eye  should  always  be  tested  as  a  control. 

Oblique  illumination  is  a  method  of  examination  by  which 
the  cornea,  the  anterior  chamber,  the  iris,  and,  if  the  pupil  is  dilated,  the 
lens  and  even  the  anterior  layers  of  the  vitreous  may  be  studied.  The 
surgeon  places  the  patient  2  feet  from  the  source  of  illumination,  and 
focuses  a  beam  of  hght  with  a  2-  or  3-inch  lens  upon  the  cornea,  at  the 
same  time  observing  the  surface  under  examination  through  a  lens  of 
the  same  focal  distance,  held  between  the  thumb  and  forefinger,  the  dis- 
engaged fingers  being  utihzed  to  elevate  the  upper  Ud  (Fig.  28). 

The  distance  of  the  lens  must  be  varied  slightly,  according  as  the 
cornea,  iris,  or  crystaUine  lens  is  brought  within  its  focus,  the  patient 
being  required  to  look  up,  down,  and  to  either  side,  while  all  the  anterior 
surfaces  and  media  of  the  eye  are  illuminated.  In  order  to  detect  for- 
eign bodies  in  the  cornea,  the  Ught  should  be  directed  at  an  acute  angle. 
If  the  posterior  pole  of  the  lens  is  to  be  examined,  the  hght  is  thrown 
perpendicularly  into  the  pupil,  the  surgeon  placing  his  eye  in  the  same 
direction  without  interfering  with  the  light. 

By  this  method  minute  abrasions,  previously  undetected  foreign 
bodies,  channels  of  old  vessels,  and  other  corneal  changes  maj'"  be  exam- 
ined. The  character  of  the  aqueous  humor,  the  depth  of  the  anterior 
chamber,  the  surface  of  the  iris,  the  presence  of  synechise,  small  tumors, 
atrophic  fibers,  and  persisting  pupillary  membrane  are  evident,  and, 
finally,  opacities  in  the  anterior  capsule  and  axis  of  the  lens  are 
discoverable. 

The  use  of  obHque  illumination  by  focusing  day  Hght  on  the 
cornea  with  a  lens  and  examining  its  surface  from  above  with  a 
strong  magnifying  glass,  as  Duane  maintains,  affords  distinct  advan- 


52     EXTERNAL  EXAMINATION  OF  THE  EYE — FUNCTIONAL  TESTING 

tages,  not  only  in  detecting  small  lesions,  but  also  distortions  of  the 
cornea  reflex  (compare  p.  50,  inspection  of  cornea). 

The  Corneal  Loupe. — This  is  a  lens,  properly  mounted,  by  means 
of  which  tile  cornea  is  strongly  magnified,  and  which  should  be  em- 
ployed with  oljli(iue  or  electric  flush-lamp  illumination. 

Dr.  Edward  Jackson  has  designed  a  binocular  magnifying  lens  which 
possesses  material  advantages.  Berger  has  constructed  on  the  same 
principle  a  useful  binocular  corneal  loupe,  the  value  of  which  is  en- 
hanced by  the  attachment  of  an  electric  lamp  as  designed  by  Shum- 
way,  and  E.  Treacher  Collins  has  arranged  a  binocular  magnifier 
mounted  on  a  spectacle  frame,  similar  to  the  Hess  loupe,  which  also 
carries  an  electric  lamp.  The  Zeiss  hinocidar  magnifier  is  a  most 
useful  instrument,  its  optical  system  being  so  constructed  that  plane 
surfaces  appear  flat  to  the  eyes. 


Fig.  28. — Method  of  oblique  illumination. 


Corneal  Microscope. — A  "corneal  microscope"  or  a  specially 
prepared  lens  of  liigh-power  permits  the  study  of  minute  changes  in 
this  membrane  and  in  the  iris,  and  is  utilized  for  the  examination  of 
the  traces  of  former  vascularization,  particularly  after  interstitial 
keratitis  (see  page  288),  and  by  its  help  even  the  circulation  of  the 
blood  in  the  vessels  of  a  pannus  may  l)e  studitnl.  The  Zeiss  conical 
microscopes  is  particularly  valuable  in  these  respects.  Its  method 
of  illumination  is,  however,  not  entirely  satisfactory  and  should  be 
enhanced  by  means,  for  example,  of  a  Xernst  lam]).  In  these  cir- 
cumstances studies  of  the  cornea,  iris,  lens  and  circuinl.ateral  sp.ace 
are  ])articulaily  salist'actoiy. 

The  Color  of  the  Iris.  The  color  of  the  iiidcs  varies:  l)lue  ami 
gray  arts  the  predominating  lines  in  nortliein  countries;  brown  occurs 
next  in  frecjuency;  while  the  various  admixtures  produce  yellow  and 
green  shades.  HIaek  irides  are  never  seen;  but  dark  irides.  taking  \\\\o 
account    the  whole  popul;ilioii  of  tlie  woild,  arc  of  tlic  most   frc(iucn( 


I 


THE    PUPIL  53 

occurrence.  The  color  of  the  iris  depends  upon  the  amount  and  loca- 
tion of  the  pigment  in  it.  Thus,  if  the  coloring-matter  does  not  exist. 
in  the  stroma,  but  only  in  the  posterior  layer,  the  blue  iris  is  evident, 
but  if  there  is  much  pigment  in  the  stroma,  the  brown  or  dark-brown 
iris  appears.  The  color  of  the  iris  of  practically  all  newborn  children, 
negro  infants  not  excepted,  is  of  a  light,  grayish  blue;  the  stromal 
pigment  is  developed  subsequently.^  According  to  Schindler  the  irides 
of  badly  nourished  very  young  children,  especially  those  with  disturb- 
ances of  digestion  or  metabolism,  may  change  to  a  gray  or  brownish  tint, 
at  an  age  when  as  a  rule  normal  infants  still  retain  the  blue  color. 

Slight  differences  in  shade  between  the  two  irides  are  not  uncom- 
mon; more  rarely,  even  in  health,  the  irides  differ  in  color  (chromatic 
asymmetry,  heterochromia  iridis),  one  being  brown  or  greenish,  the 
other  blue  or  gray.  Almost  invariably,  in  cases  of  this  sort,  one  iris 
corresponds  in  color  with  the  irides  of  one  parent,  and  the  remaining 
iris  with  those  of  the  other  parent.  Instead  of  uniform  pigmentation, 
a  single  triangular  patch  or  several  irregular  spots  of  dark  color  may 
appear  upon  one  or  both  irides  (piebald  irides).  Such  dark  spots,  if 
small,  have  been  mistaken  for  foreign  bodies  by  inaccurate  observers. 
This  condition  is  sometimes  temporary.  Chromatic  asymmetry, 
while  perfectly  compatible  with  health,  has  been  observed  in  patients 
with  neuropathic  tendencies — chorea  and  epilepsy  (Fere) ;  the  pupil 
of  the  blue  eye  may  be  smaller  than  that  of  the  fellow  eye ;  physiologic 
albuminuria  may  be  present  (T.  Harrison  Butler). 

In  many  instances  there  is  liability  to  disease  on  the  part  of  the 
lighter  eye  (cataract,  cychtis,  glaucoma);  indeed,  the  evidences  of 
cyclitis,  according  to  Fuchs,  are  nearly  always  present.  For  this 
complicated  type  T.  Harrison  Butler  suggests  the  name  heterochromic 
cyclitis.  Calhoun  prefers  Fuchs's  descriptive  term — chronic  cyclitis 
with  decoloration  of  the  iris.  Examination  reveals  punctate  keratitis, 
vitreous  opacities,  sometimes  choroiditis  and  cataract;  glaucoma  may 
develop.  The  opaque  lens  may  be  extracted  and  the  Jesuits  of  opera- 
tion are  usually  successful  (Butler,  Ellett,  Knapp)  A.  Knapp  has 
noted  reaction  to  subcutaneous  tuberculin  tests  and  improvement 
under  the  influence  of  tuberculin  therapy.  Heterochromia  iridis  may 
appear  in  several  members  of  the  same  family.  The  deficiency  of  pig- 
ment has  been  attributed  to  a  lesion  of  the  cervical  sympathetic; 
Calhoun  believes  that  in  a  large  percentage  of  the  cases  paralysis  of 
the  sympathetic  is  the  responsible  cause  for  this  heterochromia  through 
its  trophic  disturbances. 

Discoloration  from  disease  results  in  one  iris  being  green,  that  of  the 
fellow  eye  being  blue,  and  indicates  iritis  or  cychtis;  it  is  often  an  early 
symptom  of  inflammation  of  the  iris,  and  should  be  looked  for  in 
every  inflamed  eye. 

The  Pupil. — ^The  size  of  the  pupil  in  health  varies  with  exposure 

to  light  and  with  accommodation  and  convergence.     Changes  in  its 

1  Ely  records  two  dark  irides  in  more  than  1 000  newborn  children;  one  child  was 
a  negro. 


54     EXTERNAL  EXAMINATION  OF  THE  EYE — FUNCTIONAL  TESTING 

width  also  depend  upon  the  quantity  of  blood  in  the  vessels  of  the  iris, 
the  elasticity  of  the  iris-tissue,  and  certain  mechanical  conditions. 

Under  normal  conditions  the  pupils — subject  as  they  are  to  many 
influences — manifest  certain  fluctuations,  amounting,  according  to 
Schwarz,  to  0.3  mm.,  even  where  the  chief  factors  are  practically  con- 
stant. The  pupil  is  generally  small  in  old  age,  in  the  newborn,  and  in 
eyes  with  hyperopic  refraction;  it  is  larger  in  youth,  and  in  eyes  with 
myopic  refraction.  Women  are  apt  to  have  wider  pupils  than  men. 
Exceptions  to  these  statements  are  not  infrequent,  especially  in  so  far 
as  the  relation  of  errors  of  refraction  to  pupil-width  is  concerned. 
Usually  it  is  stated  that  the  pupil  is  smaller  in  blue  irides  than  in  dark 
ones.  Some  recent  investigations  indicate  that  this  is  not  the  case. 
With  the  accommodation  at  rest,  the  diameter  of  the  pupil  varies  in 
daylight  from  2.44  to  5.82  mm.,  the  average  diameter  being  4.14  mm. 
(Woinow).  The  pupil  as  seen  through  the  magnifj-ing  lens  formed 
by  the  cornea  is  about  one-ninth  larger  than  the  actual  pupil  (Duane). 
The  position  of  the  pupil  is  a  Httle  to  the  nasal  side  of  the  center  of  the 
cornea,  and,  under  similar  illumination,  the  pupils  should  be  round  and 
of  equal  size  (see  also  page  55).  Slight  inequality  of  the  pupils  is 
sometimes  seen  in  healthy  persons,  and  may  be  a  congenital  condition. 
Several  instances  of  cat-like  pupils  have  been  observed  in  human 
eyes.  In  these  circumstances  the  pupil  in  strong  illumination  takes 
on  the  form  of  a  narrow  elliptical  sht  (Greeff). 

In  addition  to  the  factors  already  detailed  which  influence  the  size 
of  the  pupil,  the  adaptation  of  the  retina  to  light  must  be  taken  into 
account,  as  Schirmer  has  shown.  The  pupil  is  exposed  to  clear  day- 
light coming  through  a  large  window  1  meter  distant,  and  the  eye  is 
permitted  an  adaptation  of  three  minutes.  Under  such  conditions  a 
difiference  in  width  of  0.25  mm.  has  been  determined.  For  the  physio- 
logic size  of  the  pupil  thus  obtained  Schwarz  prefers  the  term  adapted 
width  of  the  pupil. 

It  is  much  to  be  regretted  that  the  recorded  variations  in  tlie  diam- 
eter of  the  pupil  are  commonly  imperfect,  and  that  the  loose  state- 
ments, "pupils  dilated,"  "pupils  contracted,"  "pupils  medium-sized," 
have  crept  into  many  reports. 

Measurement  of  the  Pupil. — The  pupil  can  be  measured  approxi- 
mately l)v  holding  before  it  a  rule,  marked  in  millimeters,  and  noting 
the  number  of  spaces  its  width  occupies.  The  chief  objection  to  this 
method  is  that  the  distance  subtended  on  the  rule  is  less  than  the  diam- 
eter of  the  pupil,  in  proportion  as  the  distance  from  the  observer's  eye 
is  less  to  the  rule  than  to  the  pupil  (Jackson). 

A  great  variety  of  instruments,  known  as  pupillometcrs.  have  been 
devised  for  the  accurate  measurement  of  the  width  of  the  pupil.  A 
simple  and  serviceable  device  is  an  instrument  which  consists  of  a  scale 
of  circles  held  close  to  the  observed  eye,  the  scale  being  rotated  until 
tliat  circle  which  matches  the  pupil  in  size  is  reached  (Fig.  29). 
Priestley  Smith's  kvratometer  (see  page  51)  may  be  used  for  the  same 
purpose,     llaab's  pupillometer,  which  consists  of  a  number  of  i)lack 


MOBILITY    OF    THE    IRIS  55 

disks,  varying  from  1.5  to  8  mm.  in  diameter,  arranged  in  a  perpendicu- 
lar row,  with  which  the  pupil  is  compared,  is  a  useful  instrument.  Care 
must  be  taken  that  the  hand  using  these  instruments  does  not  cast  a 
shadow  on  the  examined  eye.  Such  examinations  suffice  for  ordinary 
clinical  work.  For  more  exact  determinations  the  photographic 
method  ofipupillometry  is  employed. 

Mobility  of  the  Iris. — PupiUreflexes. — The  mobility  of  the  iris 
is  tested  to  find  the  presence  of  attachments  between  the  iris  and  the 
lens  (synechise) ,  or  atrophy  of  the  iris,  or  to  ascertain  the  sensitiveness 
to  light  of  the  retina  or  visual  center. 

Variations  in  the  size  of  the  pupil  depend  upon  variations  in  the 
contractility  of  the  iris  and  upon  alterations  in  the  lumen  of  its  blood- 
vessels. These  pupillary  movements^  are  controlled  by  the  pupil 
muscles  (see  page  57)  which  are  set  in  motion  either  by  reflex  stimuli,  or 
by  association  with  other  voluntary  or  involuntarj-  movements,  that  is, 
by  synkinesis,  to  adopt  Parsons'  term.  Such  movements  are  often 
called  pupil-reactions  or  pupil-reflexes.     They  are  as  follows: 


Fig.  29. — Simple  pupillometer. 

1.  The  direct  light-reflex  of  the  pupil — that  is,  the  contraction  of  the 
pupil  obtained  by  illuminating  the  pupillary  area.  It  may  be  tested 
as  follows :  The  patient  is  placed  before  a  window  in  diffuse  daylight, 
and  one  eye  is  carefully  excluded.  He  is  directed  to  look  into  the  dis- 
tance with  the  exposed  eye,  which  is  then  shaded,  and,  if  it  is  normal,  a 
considerable  dilatation  of  the  pupil  will  occur.  On  removing  the 
covering  hand  or  card,  contraction  to  the  same  size  as  that  which 
existed  before  the  test  was  applied  takes  place.  The  test  may  also  be 
conducted  in  the  following  manner:  The  patient  is  seated  as  before 
described,  and  both  eyes,  which  gaze  steadily  in  the  direction  of  the  light, 
are  covered  with  the  examiner's  hand  or  a  card,  and  after  a  few  seconds 
the  cover  is  removed  from  one  eye  and  the  initial  width  and  the  rapid- 
ity and  completeness  of  the  contraction  of  the  exposed  pupil  is  ob- 
served. The  same  procedure  is  repeated  with  the  other  eye.  Again, 
inasmuch  as  a  properly  lighted  window  is  not  always  available,  the 
test  should  be  made  with  artificial  illumination.     The  patient  is  seated 

^  This  term  is  so  well  established  and  so  commonly  employed  by  clinicians  that, 
in  spite  of  the  objections  to  it  which  have  been  urged,  it  should  be  retained. 


56     EXTERNAL  EXAMINATlOjLOF  THE  EYE-^FUXCTIONAL  TESTING 

in  a  dark  room  in  front  of  riie  source  of  illuniination  (Arijand  burner, 
Welsbach  light,  lamp,  or  electric  light),  and  looks  into  distance.  Con- 
vergence and  accommodation  are  rela.xed,  and  the  diameter  of  the 
pupil  is  measured  with  a  pupillonicter.  Next,  light  is  reflected  into 
the  eye  with  the  ophthalmoscope  mirror  and  the  pupil  reaction  noted. 
Finally,  the  patient  is  required  to  face  the  liglit.  The  observer,  stand- 
ing on  one  side  and  watching  the  eye  through  a  magnifying  glass 
(Treacher  Collins'  binocular  magnifier  is  excellent  for  this  purpose), 
suddenly,  bj'  means  of  a  lens,  directs  a  beam  of  light  ilirectly  on  the 
center  of  the  cornea.  In  the  presence  of  the  slightest  light  reaction 
the  pupil  will  contract.  Satisfactory  re^ults  are  obtained  if  the  source 
of  illumination  is  a  narrow  beam  of  electric  light  obtained,  for  example, 
from  a  Wiirdemann  transilluminator  (see  page  391)  upon  which  a  cap 
containing  a  small  condensing  lens  is  fitted,  as  in  the  model  designed 
by  Veasey. 

2.  The  consensual  light-reflex,  or  indirect  reflex  action  of  the  pupil — 
that  is,  the  contraction  of  the  pupil  of  one  eye,  which  is  evident  when  the 
pupillar}'  area  of  the  opposite  eye  is  illuminated.  The  test  is  made  as 
follows:  One  eye  is  completely  excluded  from  the  source  of  illumina- 
tion, and  the  other  shaded  in  such  a  manner  that  the  pupil  can  be 
observed  beneath  the  cover.  The  completely  excluded  eye  is  next 
uncovered  and  the  light  directed  into  its  pupil,  the  reaction  which 
occurs  in  the  shaded  pupil  being  at  the  same  time  observed.  Although 
the  pupil  of  one  eye  acts  under  normal  conditions  in  unison  with  its 
fellow,  the  direct  and  indirect  reactions  are  not  equal  in  intensity. 
According  to  Bach,  the  direct  reaction  to  light  is  greater  than  the 
consensual.  The  statement,  often  made,  that  in  normal  eyes  the 
pupils  should  be  equal,  not  only  with  both  eyes  open  but  with  one  e}e 
shaded,  is  not  strictly  correct,  and  usually  the  ditference  in  wiilth  may 
be  demonstrated  by  allowing  for  some  seconds  the  stronger  illumina- 
tion to  fall  on  one  pupil  (Bach). 

3.  The  accommodation-  and  convergence-reaction,  calltnl  also  the 
associated  action  of  the  pupil,  or  tlu;  accomfuodation  !<ynkine)<is — that  is, 
the  contraction  of  the  pupil  which  takes  place  when  the  visual  axes 
converge  upon  a  near  point  Usually  the  test  is  made  as  follows:  The 
patient  is  required  to  look  into  distance  and  then  tiuickly  to  direct  his 
eyes  at  a  near  object — for  example,  the  i)oint  of  a  jji'iicil  held  at  a  «lis- 
tance  of  about  10  cm.  I'nder  normal  conditions  a  contraction  of  the 
pupils  will  occur — that  is,  the  sphincter  of  the  iris  contracts  in  asso- 
ciation with  the  ciliary  muscle  and  the  internal  recti.  Bach's  proced- 
ure is  the  following:  The  patient,  seated  facing  a  wall  between  two 
windows,  is  rc(|uin'd  to  obsei've  for  twenty  seconds  a  small  white  button 
placed  oU  cm.  from  his  (!yes.  The  button  is  then  gradually  apj)roached. 
No  change  in  the  pupil  is  observed  until  the  object  reaches  a  dis- 
tance of  40  cm.  from  the  eye,  as  it  is  usually  gradual  at  first,  ^^'hen  a 
distance  ol  20  la  cm.  is  reached  the  contraction  is  stronger  ami  may 
oc(;nr  suddcsnly,  associated  with  a  strong  convergence  impulse.  The 
amj)litud(!  of  contraction,  which  is  less  marked  than  that  whii-h  follows 


INNERVATION  OF  IRIS  AND  EXPLANATION  OF  PUPIL-REFLEXES  •  57 

the  action  of  light,  varies  between  0.25  and  0.75  mm.;  exceptionally  it 
is  greater.  Generally,  it  is  less  marked  in  old  than  in  young  persons. 
Refraction  anomaUes,  according  to  Bach,  produce  no  marked  difference 
in  the  degree  of  contraction  during  convergence,  except  that  in  high 
myopia  the  reaction  is  sometimes  delayed  and  less  in  amplitude.  The 
associated  movement  of  the  pupil  is  much  more  closely  connected  with 
convergence  than  with  accommodation;  indeed,  it  is  chiefly  due  to  the 
impulse  of  convergence.  If,  experimentally,  accommodation  and  con- 
vergence are  dissociated,  accommodation  may  take  place  without  pupil 
contraction,  but  convergence  cannot  occur  without  contraction  of  the 
pupil  (Swanzy  and  Werner). 

4.  The  sensory  reflex  of  the  pupil,  sometimes  called  the  skin-reflex, 
or  the  pain-reaction — that  is,  a  slight  dilatation  of  the  pupil  which  occurs 
on  stimulating  sensory  nerves.  It  may  be  tested  by  pinching  the  skin 
of  the  neck,  or,  better,  by  applying  to  it  a  faradic  brush. 

5.  The  cerebral  cortex  reflex  of  the  pupil  is  thus  described  bj^  its  dis- 
coverer. Dr.  Haab:  "If  in  a  room  illuminated  only  by  a  lamp  or  candle- 
flame,  the  light  is  placed  so  that  it  will  shine  laterally  into  a  person's 
eyes  while  they  look  directly  forward  into  the  darkness,  a  marked  con- 
traction of  both  pupils  takes  place  whenever  the  attention  is  directed 
toward  the  hght,  with  no  change  in  the  position  of  the  eyes.  As  long 
as  the  attention  is  directed  to  the  light  and  fixation  of  the  eyes  on  the 
dark  wall  is  maintained  the  pupils  remain  contracted,  but  as  soon  as 
the  attention  is  transferred  to  the  point  of  fixation  they  dilate,  although 
the  quantity  of  light  entering  the  eye  has  remained  constant  and  all 
movements  of  accommodation  and  convergence  are  excluded." 

The  chnical. significance  of  this  reflex  has  not  been  ascertained,  al- 
though Haab  believes  it  may  have  some  important  bearing  on  the 
theory  of  attention,  and  that  it  should  be  investigated  in  all  patients 
submitted  to  neurologic  examination. 

The  observation  of  Piltz  that  in  some  persons  the  pupils  contract 
or  dilate  when  they  call  up  a  vivid  mental  picture  of  a  bright  or  dark 
object  has  given  rise  to  the  term  imagination  reflex  of  the  pupils. 

6.  The  palpebral  (lid-closure)  reflex  of  the  pupil,  also  denominated 
the  orbicularis  pupillary  reaction,  the  Gifibrd-Galassi  reflex,  and  the 
Westphal-Piltz  reaction,  was  discovered  by  von  Graefe.  It  consists 
in  a  contraction  of  the  pupil  which  occurs  when  a  forcible  effort  is  made 
to  close  the  hds.  It  has  been  explained  by  assuming  that  an  associated 
stimulation  of  the  sphincter  nucleus  takes  place  during  closure  of  the 
lid,  or  that  it  is  due  to  the  mechanical  effect  produced  by  strong  con- 
traction of  the  orbicularis. 

When  a  pupil  has  been  contracted  under  the  influence  of  light,  con- 
vergence, or  accommodation,  and  the  stimulus  is  withdrawn,  the  pupil 
will  return  to  the  size  it  had  been  before  the  stimulus  was  apphed,  if  the 
conditions  remain  the  same.  This  return  or  relaxation  has  been  called 
by  Walter  Jessop  the  dilatation-  or  relaxation-reflex  of  the  pupil. 

Innervation  of  the  Iris  and  Explanation  of  the  Pupil  =reflexes. 
The  muscular  tissue  of  the  iris  is  divided  into  the  sphincter  pupillce, 


58     EXTERNAL  EXAMINATION  OF  THE  ETE — FUNCTIONAL  TESTING 

a  well-marked  circular  band  of  involuntary  muscle  surrounding  the 
pupillary  margin  of  the  iris,  and  certain  radially  placed  fibers,  much 
less  clearly  marked,  situated  near  the  posterior  surface,  called  the 
dilatator  pupilloe.^     These  two  muscles  are  called  the  pupillary  muscles, 


Vnajiai 


Dil. 


cej-i'  ffymp. 


■sp.  I  A 


Fig.  30. — Diagram  of  the  efferent  pupillary  paths.  Dotted  lines,  pupilloconstrictor 
///  nuc,  nucleus  of  third  nerve;  c.  g.,  ciliary  ganglion;  s.  c,  short  ciliary  nerves.  Solid 
lines,  pupillodilatator:  Dil.,  hypothetical  dilatator  center  in  the  medulla;  c.c-sp.  «'.. 
Budge's  centrum  ciliospinale  inferius;  1)1,  l)II,  Dili,  first,  S3cond.  and  third  dorsal 
nerves;  r.  c,  ramus  conmiunicans;  Stellate  a-,  stellate  ganglion;  ann.  V.  annulus  of  Vieus- 
sens; I.  c.  g.,  inferior  cervical  ganglion;  ccrv.  symp.,  cervical  sympathetic;  s.  c.  g-,  superior 
cervical  ganglion;  Gasn.  g.,  (ia.s.serian  ganglion;  VI.  V^,  VS.  first,  second,  and  third 
divisions  of  the  fifth  nerve;  T  juisal,  nasal  branch  of  the  ophthalmic  (drsi)  division  of 
the  fifth  nerve;  /.  r.,  long  ciliary  nerves.  (Description  and  diagram  from  J.  Herbert 
Parsons.) 


and  each  has  a  separate  and  independent  motor-nerve  supply  whicii 
constitute  the  miotic  and  mydriatic  nerves. 

The  liiird  (oculomotor)  nerve  innervates  the  sphincter  of  tiie  pupil, 

'  The  existence  of  a  dilator  muscle  in  the  iris  is  denied  by  st)ine  authors,  but  the 
combined  anatomic  and  jjliysioloRic  evidence  of  its  presence  seems  to  be  conclusive. 


INNERVATION  OF  IRIS  AND  EXPLANATION  OF  PUPIL-REFLEXES     59 

and  contains  the  pupillo-constricting  fibers  which  arise  from  its  nucleus 
in  the  aqueduct  of  Sylvius.  From  this  point  the  fibers  proceed  in  the 
main  trunk  of  the  nerve  to  the  orbit,  and  pass  into  the  branch  which 
supplies  the  inferior  oblique,  which  they  leave  by  way  of  the  twig  which 
constitutes  the  short  root  of  the  ciliary  ganglion,^  and  finally  arrive  at 
the  sphincter  by  the  short  ciliary  nerves  which  penetrate  the  sclera 
around  the  optic  nerve,  and  pass  forward  in  the  choroid  and  ciliary 
body  to  their  destination  in  the  iris.  This  hne  of  communication  be- 
tween the  nucleus  of  the  third  nerve  and  the  sphincter  of  the  pupil  is 
called  the  miotic  tract  or  efferent  path,  and  is  also  known  as  the  centrifu- 
gal  pathway  of  the  pupil  reflex.  Stimulation  of  it  produces  contrac- 
tion of  the  pupil;  section  of  it,  moderate  dilatation. 

The  cervical  sympathetic  innervates  the  dilatator  of  the  pupil. 
The  dilatator  tract  proceeds  from  a  center  in  the  medulla  (or  from  a 
point  in  the  aqueduct)  into  the  lateral  columns  of  the  spinal  cord  as 
far  as  the  third  dorsal  nerve.  The  pupillodilating  fibers  leave  the 
cord  by  the  ventral  roots  of  the  first,  second,  and  third  dorsal  nerves 
and  follow  their  communicating  branches  to  the  superior  cervical 
ganglion.  They  pass  upward  in  the  ascending  or  carotid  branch  of  the 
first  cervical  ganglion  and  arrive  at  the  plexus  around  the  internal 
carotid  and  the  Gasserian  ganglion.  They  reach  the  eyeball  through 
the  nasal  branch  of  the  ophthalmic  nerve  and  its  long  ciliary  nerves 
which  perforate  the  sclera,  and  are  distributed  to  the  ciliarj^  muscle  and 
iris.  The  tract  just  described  is  called  the  mydriatic  tract.  Stimu- 
lation of  it  causes  dilatation  of  the  pupil;  section  of  it,  moderate  con- 
traction (Fig.  30). 

Inasmuch  as  the  iris  is  not  under  the  control  of  the  will,  the  con- 
traction of  the  pupil  which  occurs  when  the  eye  is  exposed  to  the  source 
of  light  in  the  manner  described  is  a  reflex — that  is,  its  motor  nerves  are 
excited  to  action  indirectly  by  the  reflex  stimulus  of  light.  This  light 
reflex  is  under  the  control  of  the  constrictor  center,  which  the  stimuli 
reach  by  passing  along  a  tract  which  is  known  as  the  afferent  pathway, 
the  exact  course  of  which  is  as  yet  uncertain,  but  it  is  probably  some- 
what as  follows:  The  fibers  of  the  pupil-reflex  tract  begin  in  the  retina 
and  arise  from  all  parts  of  it  and  proceed  in  the  optic  nerves,  and  are 
in  all  probability  to  be  histologically  differentiated  from  those  which 
are  concerned  with  vision.^  In  the  chiasm  these  pupillary  fibers 
undergo  partial  decussation  and  enter  the  optic  tracts,  which  they 
leave  just  in  advance  of  the  external  (lateral)  geniculate  body,  and 
reach  the  third  nerve  nucleus.  From  a  special  part  of  this  nucleus, 
probably  the  small-celled  median  nuclei,  the  pupilloconstrictor  fibers 

^  As  Langley  and  Anderson  have  shown,  there  is  a  cell-station  in  the  ciliary 
ganghon.  The  root-fibers  which  belong  to  the  oculomotor  end  in  the  ganglion, 
and  with  the  cells  of  the  cihary  ganghon  a  new  neuron  begins  for  the  fibers  which 
pass  to  the  cihary  muscle  and  the  sphincter  of  the  pupil. 

^  According  to  some  observers  (Hess)  the  portion  of  the  retina  which  receives 
the  Ught  rays,  giving  origin  to  the  pupil-reflexes,  is  confined  to  a  small  central 
area  with  a  radius  of  about  3  mm. 


60     EXTERNAL  EXAMINATION  OF  THE  EYE — FUNCTIONAL  TESTING 

arise  and  reach  the  sphincter  of  the  iris,  constituting  the  efferent, 
miotic,  or  centrifugal  pathway  already  described*  (Fig.  31). 

The  direct  hght  reflex  of  the  pupil  is  the  result  of  an  active  con- 
strictor effect,  the  stimuli  passing  along  the  afferent  pathway  to  the 
sphincter  center  in  the  third  nucleus,  and  from  tliere  by  the  efferent 
pathway  to  the  termination  of  the  miotic  fibers  in  the  iris. 

The  consensual  or  indirect  hght  reflex  of  the  pupil  occurs  because 
the  stimulus  passes  to  the  opposite  eye,  either  by  reason  of  the  decussa- 
tion of  the  fibers  in  the  chiasm  or  because  of  its  transference  from  one 
nucleus  to  the  other. 


Fig.  '.i\. — Diagram  of  the  afftTcnt  aiul  efTereiit  i)iipillary  paths  for  linht  stinmli. 
Afferent  paths  from  loft  sides  of  rctinte,  thick  solid  lines;  afTorcnt  paths  from  ri^;ht  sides 
of  retina>,  thick  dotted  lines;  efferent  paths.of  left  eye.  thin  solid  lines;  efferent  paths  of 
right  eye,  thin  dotted  lines:  Ir.,  iris;  R,  retina;  //,  optic  nerve;  o.  tr.,  optic  tract;  i'oU. 
Supr.,  colliculus  superior  or  anterior  corpus  quadriKenunum;  Illrd.  nuc,  nucleus  of 
third  nerve;  e.  g.  b.,  external  geniculate  body;  c.  g.,  ciliary  ganglion;  s.  c.  n.,  short  ciliary 
nerves.     (Description  and  diagram  from  .1.  Herbert  Parsons.) 

The  sensory  reflex  of  the  pupil  is  a  dilator  reflex  calliHl  into  existence 
by  various  sensory  stimuli.     Accorchng  to  Parsons,  it  is  ilui>  in  part  to 

'  The  path  by  which  the  j)upillary  fil)er.s  leave  the  optic  tract  to  nnu-ii  tl>e  thiril 
nucleus,  in  the  lanKuage  of  I'arsons,  is  as  yet  conjectural.  This  author,  referring 
to  the  i)ii|)illo-c<)n.strictor  path,  thinks  it  is  proliablc  that  the  fil)ers  pa.ss  thrnunh 
the  Buj)eri(jr  brachiuiu  of  the  (piadrineminal  body  to  the  superior  colliculus,  there 
niakiiij^  new  connections  witii  the  cells  which  convey  the  iini)ulscs  to  the  third 
nucleus  of  the  same  and  also  the  opposite  side.  Von  Hijipel  st.-itcs  that  after  the 
pupil  fibers  leave  a  tract  in  advance  of  tiie  external  neiiiculate  body,  they  run  up 
and  in  tcnvard  the  median  line,  and  as  they  enter  the  white  subst.uncc  of  the  corponi 
quadrinemina,  they  radiate,  part  of  thcin  noing  to  the  roof,  and  another  part, 
under  the  atpieduct,  toward  the  s|)hiiictcr  nucleus.  It  is  probable  that  there  is  a 
connecti<in  between  the  two  sphincter  luiiiei  over  tlie  median  line  tlirou^h  the 
ganKliori-<-ell  processes. 


i 


DILATATION    OF    THE    PUPIL  61 

augmentation  of  the  dilator  tone  through  the  sympathetic,  and  in  part 
to  inhibition  of  the  constrictor  tone. 

The  convergence  and  accommodation  reaction  of  the  pupil  is  not  a 
reflex,  but  an  associated  movement,  and  has  been  ascribed  to  the 
effect  of  a  stimulus  which  reaches  the  convergence  center  in  the  third 
nucleus,  and  is  diffused  to  the  cells  which  innervate  the  ciliary  muscle. 
According  to  Schwarz,  it  is  possible  that  a  single  cerebral  impulse 
to  accommodate  both  eyes  to  near  vision  stimulates  simultaneously 
the  nuclei  which  regulate  convergence,  accommodation,  and  pupil 
contraction. 

The  cerebral  cortical  reflex  or,  better,  reaction  of  the  pupil,  is  of 
complex  nature  and  results  from  psychic  stimuli.  The  explanation 
of  the  lid-closure  reflex  of  the  pupil  has  been  given  (see  page  57). 

Not  only  may  constriction  of  the  iris,  and  therefore  contraction  of 
the  pupil,  be  due  to  contraction  of  the  constrictor  (sphincter)  muscle, 
but  it  also  may  be  caused  by  relaxation  of  the  dilatator  muscle  and 
dilatation  of  the  blood-vessels  of  the  iris.  As  before  stated,  the 
evidence  strongly  indicates  that  the  light  reflex  is  an  active  constrictor 
effect,  although  some  writers  maintain  that  it  should  be  explained  by 
an  inhibitory  dilatator  influence.  Instead  of  locating  the  center  for 
the  hght  reflex  of  the  pupil  in  the  small  cells  which  occupy  the  median 
part  of  the  third  nucleus,  Marina  has  placed  it  in  the  cihary  ganglion. 
Bach  has  described  an  inhibitory  constrictor  and  an  inhibitory  dilata- 
tor center  in  the  spinal  end  of  the  floor  of  the  fourth  ventricle,  and. 
according  to  him,  irritation  of  these  centers  will  cause  either  dilatation 
or  contraction  of  the  pupil.  The  presence  of  these  centers  is  denied 
by  a  number  of  observers. 

Not  only  may  dilatation  of  the  pupil  be  due  to  contraction  of  the 
dilatator  muscle  (dilatator  pupillse),  but  may  also  be  caused  by  relaxa- 
tion of  the  constrictor  (sphincter)  muscle  and  to  constriction  of  the 
blood-vessels  in  the  iris.  The  dilatator  pathway  has  been  described 
(see  page  58).  Budge  and  Waller  believed  that  the  origin  of  the 
pupil-dilating  fibers  should  be  referred  to  the  spinal  cord  in  a  region 
between  the  exits  of  the  sixth  cervical  and  fourth  dorsal  or  thoracic 
nerve  (probably  opposite  the  seventh  cervical  and  first  thoracic), 
which  is  known  as  Budgets  ciliospinal  center  (see  Fig.  30).  Although 
certain  cHnical  and  experimental  evidence  is  in  favor  of  this  center, 
its  existence  has  not  been  proved."  Not  only  is  the  sympathetic 
pathway  of  the  pupils  concerned  with  maintaining  a  certain  tone  in 
the  dilatator  muscle  of  the  iris,  but  it  is  also  capable  of  being  actively 
awakened  by  various  sensory  stimuU. 

Dilatation  of  the  pupil  occurs  in  glaucoma,  in  optic-nerve 
atrophy,  in  orbital  disease,  and  under  the  influence  of  mydriatics.  It 
is  further  seen  in  fright,  emotion,  in  deep  inspiration  or  expiration, 
anemia,  in  depressed  nervous  tone,  aortic  insufficiency,  cutaneous 
stimulation  (skin-reflex),  and  irritation  of  the  cervical  sympathetic. 
If  paralysis  of  accommodation  is  associated  with  dilatation  of  the 
pupil,  objects  may  appear  smaller  than  normal  (micropsia). 


62     EXTERNAL  EXAMINATION  OF  THE  EYE — FUNCTIONAL  TESTING 

In  diseases  of  the  nervous  sj^stem,  dilatation  of  the  pupil,  if  of 
cerebral  origin,  indicates  extensive  lesion;  if  of  spinal  origin,  irrita- 
tion of  the  part  (McEwen).  Systematic  writers  have  divided  dilata- 
tion into  irritation  mydriasis,  caused  by  irritation  of  the  pupil-dilating 
center  or  fibers,  and  paralytic  mydriasis  (iridoplegia),  caused  by 
paralysis  of  the  pupil-contracting  center  or  fibers. 

In  irritation  or  spastic  mydriasis  the  pupil  may  be  moderately  or 
widely  dilated.  It  reacts  somewhat  to  light,  accommodation,  and 
convergence  if  the  dilatation  is  not  extreme;  but  if  it  is,  these  reactions 
may  be  lacking.  Cocain  usually  produces  no  further  dilatation  of  such 
a  pupil,  nor  is  it  readily  contracted  by  pilocarpin,  and  sometimes  not  at 
all.  It  is  seen  in  hyperemia  and  irritation  of  the  cervical  part  of  the 
spinal  cord,  in  spinal  meningitis,  in  tumor  of  the  cord,  sometimes  in 
tumor  of  the  cerebrum,  in  acute  mania,  and  in  earh'  tabes  dorsalis  and 
paretic  dementia.  Spasmodic  mydriasis  has  been  observed  in  a 
healthy  subject  (Cramer). 

In  paralytic  mydriasis  {sphincter  paralysis)  the  pupil  is  dilated,  but 
not  necessarily  ad  maximum.  It  does  not  react  to  light,  accommoda- 
tion, and  convergence,  and  the  condition  is  sometimes  described  as 
pupillary  rigidity  or  total  iridoplegia.  If  there  is  only  paresis  and  not 
paralysis  of  the  sphincter,  a  sluggish  reaction  to  light,  accommodation, 
and  convergence  may  be  obtained.  Cocain  still  further  dilates  a 
pupil  of  this  character,  and  it  is  contracted  by  the  action  of  pilocarpin. 

Paralytic  mydriasis  may  be  caused  bj'  a  lesion  in  the  sphincter,  the 
sphincter  nucleus,  or  the  centrifugal  tract.  It  is  seen  in  disease  of  the 
base  of  the  brain  affecting  the  third  nerve  or  its  nucleus,  in  cerebral 
lues,  in  pressure  on  the  cerebrum  great  in  degree,  in  late  stages  of 
meningitis,  in  edema  of  the  cortex,  in  cerebral  softening,  and  in  hemor- 
rhage of  the  centrum  ovale  and  cerebral  peduncles. 

In  medicinal  mydriasis — i.  e.,  one  caused  by  atropin  or  a  similar 
drug  or  by  certain  toxins — there  is  paralysis  of  accommodation,  and  the 
pupil  is  unaffected  by  pilocarpin. 

Contraction  of  the  pupil  {miosis)  appears  in  congestions  of  the 
iris,  in  traumatisms  of  the  iris  {traumatic  miosis),  in  certain  fevers, 
in  plethora,  venous  obstruction,  mitral  disease,  pulmonary  congestion, 
paralysis  of  the  sympathetic,  and  under  th(>  influence  of  miotics.  Dur- 
ing sleep  the  pupils  are  contracted.  If  spasm  of  acconnnodation  is 
associated  with  contraction  of  the  pupil,  objects  may  appear  larger 
than  normal  {macropsia). 

If  the  miosis  is  of  cerebral  origin,  it  indicates  an  early  irritative 
stag(!  of  the  affection  (inciiiiigitis,  etc.);  if  of  spinal  origin,  a  depression, 
paralyses,  or  even  destruction  of  the  part  (MclOwiMi). 

Systematic  writers  have  divided  contraction  of  the  pupil  into 
irritation  miosis,  caused  by  irritation  of  the  pupil-contracting  center  or 
fibers,  and  paralytic  miosis,  caused  by  paralysis  of  the  pupil-dilating 
center  or  fiber.  The  same  factors  which  eau.se  miosis  may  causi^ 
mydriasi.s,  the  determining  factor  l)eing  the  degree  ami  the  duration 
of  t  he  lesion. 


CONTRACTION    OF   THE    PUPIL  63 

In  irritation  or  spastic  miosis  the  pupil  is  contracted,  in  medium 
degree  if  one  etiologic  factor  is  active,  ad  maximum  if  both  are  con- 
cerned. Such  a  pupil  dilates  httle  or  not  at  all  in  the  dark,  and  usually 
is  unaffected  by  the  action  of  light.  It  is  readily  dilated  by  a  mydriatic 
(atropin),  and  still  further  contracted  by  pilocarpin.  The  active  lesion 
may  reside  in  the  iris,  in  the  sphincter  nucleus,  or  in  the  centrifugal 
pathway.  According  to  some  authors  spastic  miosis  may  be  indi- 
rectly caused  by  failure  of  the  inhibitory  influences  to  act  on  the 
sphincter  nucleus  (Schwarz). 

Irritation  or  spastic  miosis  may  be  caused  by  inflammatory  affec- 
tions of  the  base  of  the  brain  and  the  meninges  in  their  early  stages, 
by  brain  abscess,  by  beginning  sinus  disease,  in  the  early  period  of  cere- 
bral neoplasms,  in  small  hemorrhages  in  the  cerebellum,  at  the  onset 
of  cerebral  apoplexy,  and  in  apoplexy  of  the  pons.  It  is  also  seen  in 
hysteria,  at  the  beginning  of  epileptic  attacks,  in  certain  toxemias,  in 
tobacco  amblyopia,  and  under  the  influence  of  long-sustained  efforts 
of  accommodation. 

In  paralytic  miosis  {dilatator  paralysis)  the  pupil  is. contracted,  but 
its  motib'ty  is  preserved  in  that  it  reacts  to  light  and  the  impulse  of  con- 
vergence. In  the  dark  it  dilates,  but  less  perfectly  than  a  normal  pupil. 
Such  a  pupil  is  dilated  by  mydriatics,  but  only  partially;  it  is  contracted 
still  further  by  miotics. 

Paralytic  miosis  may  be  caused  by  lesions  in  the  cord  above  the 
dorsal  vertebra,  and  is  especially  noteworthy  in  tabes  dorsalis  (spinal 
miosis).  It  is  also  seen  in  paralysis  of  the  insane,  pseudodementia 
paralytica  of  syphihtic  origin,  in  some  forms  of  bulbar  paralysis,  and  in 
some  varieties  of  multiple  neuritis  (Mills).  It  is  caused  also  by  injury 
to  the  cervical  sympathetic,  or  by  pressure,  for  example,  from  enlarged 
cervical  glands  or  an  aneurysm.  If  the  cervical  sympathetic  is  para- 
lyzed, with  the  miosis  there  are  enophthalmos,  unilateral  anhidrosis 
and  ptosis  (sympathetic  ptosis,  Horner's  syndrome). 

To  a  pupil  which  does  not  react,  either  directly  or  indirectly  (consen- 
sually)  to  the  influence  of  light,  but  contracts  promptly  on  converg- 
ence of  the  visual  axes,  the  term  reflex  inactivity  or  immobility  of  the 
pupil  or  reflex  iridoplegia  is  apphed.  Usually,  it  is  denominated  the 
Argyll  Robertson  pupil.  Generally,  the  condition  is  bilateral,  but  uni- 
lateral reflex  inactivity  or  immobility  is  also  seen,  and  even  where  the 
failure  of  Hght  reaction  is  bilateral,  one  pupil  may  be"  smaller  than  the 
other,  although  both  are  miotic  pupils.  Sometimes  the  same  reflex 
immobility  is  present  when  the  pupils  are  dilated.  Frequently  the 
affected  pupils  are  not  round,  but  slightly  oval  or  pointed.  The  seat 
of  the  lesion  in  these  circumstances  is  not  certainly  known.  It  has  been 
placed  in  the  fibers  which  pass  from  the  proximal  end  of  the  optic  nerve 
to  the  oculomotor  nuclei  by  some  authors,  and  by  others  is  considered  to 
be  nuclear.  Bach  believes  that  it  may  be  located  in  the  spinal  end  of  the 
sinus  rhomboidalis,  and  Marina  and  Lafon  place  the  causal  lesion  in  the 
ciliary  ganghon.  John  Dunn  believes  that  the  Argyll  Robertson  pupil 
is  the  result  of  the  abolition  of  the  autonomic  reflex  of  the  ciHary  gangha. 


64     EXTERNAL  EXAMINATION  OF  THE  EYE — FUNCTIONAL  TESTING 

Reflex  iimnubile  or  inaetive  pupils  are  especially  noteworthy  and 
frequent  in  tabes  dorsalis  (60-90  per  cent.  Uhthoff)  and  paretic  de- 
mentia (50  per  cent.  Uhthoff),  and,  as  is  well  known,  may  precede  the 
general  signs  of  these  diseases  by  many  years.  They  also  occur  in 
syphiUs,  especially  cerebral  syphiUs  (10  per  cent.  Uhthofl).  Argj'U 
Robertson  pupils  probably  can  also  be  caused  by  hereditary  syphilis 
inasmuch  as  tal^es  has  been  noted  in  virgins  with  hereditary  syphilis. 
Reflex  iri(l()i)legia  has  also  been  observed  in  non-syphilitic  affections, 
in  alcoholic  neuritis,  in  methyl  alcohol  poisoning  with  neuritis  (A. 
Fuchs)  and  after  injuries  (Magitot).  If  miosis  is  present  it  has  been 
attributed  to  a  sympathetic  affection  and  to  tonic  contraction  of  the 
sphincter,  but  Bach  thinks  that  it  depends  upon  an  irritation  of  the 
reflex  inhibitory  center  which  he  believes  he  has  discovered.  According 
to  the  same  author  the  Arg^'ll  Robertson  pupil  may  remain  unilateral 
for  years,  and  exist  as  an  isolated  symptom. 

The  reverse  of  the  Argyll  Robertson  symptoms  has  been  observed, 
that  is  to  say,  the  pupil  reacts  to  light,  but  fails  to  react  to  convergence, 
and  has  been  ascribed  to  disease  in  a  special  part  of  the  oculomotor 
nucleus. 

Unilateral  reflex  iridoplegia,  or  a  condition  in  which  one  pupil  is 
unaffected  by  varying  degrees  of  illumination  of  both  eyes,  but  reacts 
to  accommodation,  while  the  pupil  of  tiie  other  eye  respond  to  a 
separate  light  stimulus  of  either  eye,  and  which  is  seen  in  tabes  dorsahs 
and  sj^phiUtic  cases,  should  be  distinguished  from  iinilatcral  reflex 
blindness,  caused,  for  example,  bj''  interruption  of  the  conducting  power 
of  one  optic  nerve.  In  unilateral  reflex  blindess  illumination  of  the 
pupil  area  on  that  side  fails  to  ehcit  either  the  direct  or  the  indirect 
pupil-reflex. 

It  is  evident  that  in  certain  cases  as  has  been  noted,  although 
light  perception  is  present,  the  reaction  of  the  pupil  to  light  is  wanting, 
for  example,  in  changes  in  the  iris  itself,  that  is,  inflammation,  atrophy, 
laceration,  etc.,  paralysis  of  the  oculomotor  nerve  or  its  nucleus,  and 
reflex  iridoplegia.  Occasionally,  although  light  perception  is  wanting, 
the  reaction  of  the  pupil  to  light  is  pn^served.  This  may  occur  with 
lesions  interrupting  the  optic  pathway  above  the  point  where  th(^  fibers 
of  the  refl(>x  arc  pass  to  the  center  for  pupillary  movements  (Fuchs). 
Finally,  in  rare  instances,  although  light  perception  isentir(>ly  wanting 
due  to  disease  of  the  optic  nerve,  the  reaction  of  the  pupil  is  present. 
This  phenomenon  has  been  explained  by  assuming  that  the  fibers 
concerned  with  the  light  reflex  are  more  resistant  than  thosi>  which  are 
concerned  wilh  visual  impressions.  The  practical  point  is  that  response 
of  the  pupil  to  light  stinuilus  does  not  necessarily  prove  the  existence 
of  light  perception. 

Convergence  Anomalies  of  the  Pupils.  As  already  noted,  in  com- 
pl(!l('  rigi(lit\'  of  the  pupil,  such  as  occurs  with  total  paralysis  of  the 
spluMcler.  tliere  is  no  convergence  i-eaction.  but  it  is  conceivable,  aa 
Scjiwar/  points  out,  that  a  conimoii  (lisluibance  of  convergiMice  reac- 
tion and  light  reaction,  due  to  inl*  iiuption  ol"  (he  corresponding  path- 


SPECIAL    AND    PARADOXIC    PUPILLARY    PHENOMENA  65 

waj's  leading  to  the  sphincter  nucleus,  may  occur  without  paralysis'or 
the  sphincter. 

Occasionally  a  pupil  which  is  inactive  to  light  stimulus,  but  which 
contracts  on  convergence,  will  remain  in  this  contracted  condition  for 
a  considerable  length  of  time  before  it  slowly  returns  to  its  original  size. 
This  phenomenon  has  been  called  the  myotonic  pupil  movement  by 
Sanger,  and  neurotonic  convergence  reaction  by  Piltz.  It  has  been  noted 
in  tabes  dorsahs,  in  multiple  sclerosis,  migraine,  and  alcoholism. 
Failure  of  the  convergence  reaction  of  the  pupil,  unassociated  with 
disturbances  of  the  light  reflex,  although  rare,  may  occur.  It  may  be 
complete  or  incomplete,  and  the  convergence  rigidity  may  be  associ- 
ated with  parah'sis  of  accommodation,  or  this  may  be  absent. 

The  palpebral  reflex  of  the  pupil,  according  to  Bach,  may  be  seen 
in  normal  eyes,  and  is  perhaps  accountable  for  some  of  the  contradic- 
tory observations  which  have  been  made  on  the  pupil  reflexes.  If 
there  is  sphincter  paratysis  it  is  abolished,  but  sometimes  it  appears, 
although  Hght  reaction  and  convergence  reaction  are  absent,  when  it 
must  be  assumed  that  the  sphincter  itself  is  not  paralyzed,  or,  at  least, 
not  completely  disabled. 

Unequal  Pupils  {anisocoria). — The  statement  that  inequality  of 
the  pupils  is  always  pathologic,  considering  the  number  of  observations 
now  on  record,  is  subject  to  revision  and  it  would  seem  that  we  may 
safely  speak  of  pathologic  and  non-pathologic  anisocoria,  in  short  that 
slight  differences  in  the  width  of  pupils  may  be  compatible  with  perfect 
ocular  and  general  health.  As  Uhthoff  points  out  in  non-pathologic 
anisocoria  the  pupils  are  round  and  react  normally  to  the  ordinary 
stimuli  which  usually  is  not  the  case  in  pathologic  pupillary  inequaUty. 
Tarun  has  well  studied  the  subject  in  this  country.  If  there  is  recent 
wide  dilatation  of  one  pupil  and  no  disease  of  the  eye,  the  instillation  of 
a  mydriatic  may  be  suspected.  Unequal  pupils  occur  in  e\'es  with 
widely  dissimilar  refraction,  if  one  eye  is  bhnd,  in  aneurysm,  pulmonary 
tuberculosis,  dental  disease,  sinusitis,  traumatism,  and  in  diseases  of 
the  nervous  system.  If  the  disease  is  cerebral,  the  inequality  denotes 
unilateral  or  focal  brain  disease.  Anisocoria  is  not  uncommon  in  tabes, 
disseminated  sclerosis,  and  paretic  dementia. 

Varying  inequality  of  the  pupils  {springing  or  alternating  mydri- 
asis) or  a  one-sided  mydriasis,  now  occurring  on  the  one  side  and 
now  on  the  other,  may  be  a  premonitory  sj'mptom  of  insanity,  and  has 
been  noted  in  general  paralysis  and  locomotor  ataxia.  It  is  doubtful 
if  it  occurs  in  healthy  persons,  but  the  so-called  false  alternating 
mydriasis,  according  to  Piltz  and  Frenkel,  may  be  due  to  an  inequality 
in  the  reflex  excitabihty  to  hght  of  the  two  eyes,  or  to  inequality  in  the 
response  to  accommodation  or  spasm  of  the  orbicularis  muscles. 
Duane  quotes  Coats  and  von  Hippel  who  have  observed  cyclic  contrac- 
tion and  dilatation  of  the  pupil,  sometimes  with  dilatation  and  con- 
traction of  the  palpebral  fissure  in  cases  of  oculomotor  palsy. 

Special  and  Paradoxic  Pupillary  Phenomena. — The  hemiopic 
pupillary  inaction  is  referred  to  on  page  571.     Dilatation  of  the  pupil 


66     EXTERNAL  EXAMINATION  OF  THE  EYE  —FUNCTIONAL  TESTING 

under  the  influence  of  lifiht  stimulus  and  contraction  when  it  ha^  been 
shaded  have  been  described  in  cases  of  meningitis  as  paradoxic  pupillary 
reactions. 

The  phenomenon  has  been  explained  by  assuming  a  reflex  stimula- 
tion of  the  dilatator  by  a  psychic  influence,  or  that  the  action  of  the 
dilatator  is  indirectly  increased  because  there  is  rapid  exhaustion  of  the 
sphincter  (Silex).  The  opposite  condition,  paradoxic  pupil  dilatation,  is 
the  antithesis  of  the  conditions  just  described,  and  has  been  observed  fre- 
quently in  experimental  work  in  connection  with  the  relation  of  the  sym- 
pathetic to  the  eye.  Paradoxic  convergence  reaction  — that  is,  a  dilata- 
tion of  the  pupil  on  convergence  of  the  visual  axes — has  been  recorded. 

Hippus  is  a  rhythmic  contraction  and  dilatation  of  the  pupil  with- 
out alteration  of  illumination  or  fixation.  It  is  a  normal  phenomenon 
due  to  the  constantly  varying  sensitive  and  psychic  reflexes,  but 
it  may  occur  in  exaggerated  degree  in  hysteria,  mania,  meningitis,  and 
other  diseases  of  the  nervous  mechanism. 

Testing  Acuteness  of  Vision. — The  acuteness  of  vision  is  the 
power  of  distinguishing  form  and  size,  and  is  a  function  of  the  macula 
lutea,  the  peripheral  portions  of  the  retina  having  only  indifferent 
ability  to  distinguish  form  and  .size. 

In  order  to  determine  the  acuteness  of  sight,  test-types  are  em- 
ployed, in  which  the  letters  are  of  various  sizes,  and  constructed  accord- 
ing to  the  methods  described  on  page  35. 

When  it  is  desired  to  make  the  test,  the  patient  is  placed  G  meters 
from  the  type-card,  in  a  well-lighted  room,  and  each  eye  is  tried  sepa- 
rately. If  the  letters  of  No.  6  (20  feet  approximately)  are  read,  vision 
is  normal,  or  1,  but  if,  at  the  same  distance,  letters  no  smaller  than 
those  numbered  18  (60  feet)  can  be  discerned,  vision  is  i-^.     It  is  usual 

to  express  these  results  according  to  the  formula  1'  =  ,y  in  which   V 

stands  for  visual  acuteness,  d  for  the  distance  of  the  patient  from  the 
card,  and  D  for  the  distance  at  which  the  type  should  be  read;  so  that 

p  p  Of) 

in  these  instances  the  vision  would  be  recorded  tt  and  to'  or  in  feet, 

6  18  'XX 

20 
and       .     The  rays  coming  from  the  letters  at  6  meters'  distance  have 

so  little  div^ergence  when  they  reach  the  eye  that  they  are  usually  con- 
sidered parallel.  Hence,  if  the  patient  sees  distinctl3'  at  tliis  distance, 
his  vision  is  i)erfect  at  the  longest  range  (see  also  page  38).  In  point  of 
fact,  however,  there  is  an  appreciable  divergence  of  the  rays  from  the 
distance  mentioned,  equivalent  to  one-sixth  of  a  diopter,  and  in  tlie 
final  adjiisdiieiit  of  glasses  this  divergence  should  i)e  recognized.  Any 
other  distance  ni:iy  be  chosen,  pi'iJA'ided  it  d()(»s  not  place  the  patient 
closer  to  the  test-card  than  3  meters, at  which  dost*  range  the  fiinctiou 
of  acconunodation  would  introduce  an  I'lcnieiit  of  inaccuracy.  Thus, 
'  the  scale  nuide  use  of  by  de  Wecker,  and  rl;ibor.it<'(l  by  Olixcr.  assumes 

appidxiiii.itrly )    iiistend  of,.,  as   ..     'V\\r  irdi  riititiontil   ttsf-types 


5   /!■'> 
5  Vxv 


LIGHT-SENSE  67 

are  also  designed  for  a  distance  of  5  meters  and  the  visual  acuteness  is 
expressed  in  decimals.  It  is  the  custom  of  many  ophthalmologists 
to  record  the  visual  acuteness  in  a  decimal  fraction,  for  instance 
V  =  0.5  instead  of  %2-  In  like  manner,  a  4-meter  distance  may  be 
utiUzed,  as  has  been  done  by  Edward  Jackson.  This  author  urges 
the  standardizing  of  all  cards  of  test  letters  by  comparison  of  the 
visibiht}^  of  each  line  of  letters  with  that  of  a  graded  series  of  broken 
rings  which  he  has  designed  and  has  had  prepared. 

The  acuteness  of  sight,  as  tested  with  types  constructed  on  the  basis  of 
an  angle  of  5',  does  not  represent  accurately  the  highest  vision  attainable , 
indeed,  man^'  good  eyes  possess  a  vision  of  ^^  of  the  standard  angle. 
For  this  reason  Dr.  James  Wallace  arranged  a  series  of  test-types 
in  which  an  angle  of  4'  has  been  substituted  as  the  basis  of  each 
letter. 

For  the  purpose  of  a  control  test,  and  also  for  determining  visual 
acuteness  of  illiterate  persons,  cards  are  employed  on  which  a  number 
of  differently  arranged  dots  are  placed,  of  sizes  which  should  be  counted 
at  different  distances,  and  among  these  Burchardt's  international  tests 
are  the  most  useful.  For  the  same  purpose  incomplete  squares  corre- 
sponding in  size  to  the  test-letters  have  been  constructed,  the  incom- 
plete sides  being  turned  successively  in  different  directions  or  the 
broken  rings  proposed  and  designed  by  Landolt  may  be  used.  Wolff- 
berg  has  designed  a  useful  test  which  consists  of  small  pictures  of  well- 
known  objects,  which  in  size  approximately  conform  to  the  standard 
angle.  The  whole  subject  of  test  objects  for  the  illiterate  has  been 
admirably  described  by  Dr.  A.  E.  Ewing.' 

If  the  patient  fails  to  decipher  the  largest  letters  at  the  distance 
employed,  he  should  be  moved  closer  to  the  card;  thus,  he  may  be  un- 
able to  read  the  type  numbered  60  at  6  meters,  but  may  discern  this  at 

4         1 
4  meters,  V  =  ah  or  T^  of  normal.     Still  further  depreciation  of  visual 

acuteness  is  recorded  by  requiring  the  subject  to  count  the  outstretched 
fingers  at  various  distances,  0.2,  1,  or  2  meters,  V  =  counting  fingers 
at  0.2  meter,  etc.  For  determining  the  lower  degrees  of  sharpness  of 
vision  bj'  a  method  more  precise  than  the  one  just  described,  Landolt 's 
optotypes  may  be  employed.^  If  the  patient  is  unable  to  count  fingers, 
his  ability  to  perceive  the  movements  of  the  hand  at  0.5,  1,  or  2 
meters  is  tested,  V  =  movement  of  the  hand  at  0.5  meter,  etc.  When 
the  ability  to  distinguish  form  (qualitative  light  peiception)  no  longer  ex- 
ists, the  perception  of  hght  should  be  investigated  by  alternately 
screening  and  shading  the  eye,  by  illuminating  the  eye  with  light  re- 
flected from  a  mirror,  or  focused  upon  it  w'ith  a  condensing  lens. 

Light=sense. — Having  determined  the  acuteness  of  vision  by 
means  of  the  test-letters,  the  examiner  has  ascertained  the  form-sense, 
and  may  proceed  to  try  a  second  subdivision  of  the  sense  of  sight, 
the  light-sense,  which  is  the  power  possessed  by  the  retina,  or  center  of 

•  American  Journal  of  Ophthalmology,  1920,  vol.  3,  Xo.  1,  p.  5. 
2  Ophthalmic  Record,  1899,  vol.  viii,  p.  624. 


68     EXTERNAL  EXAMINATION  OF  THE  EYE  -FUNCTIONAL  TESTING 

vision,   of  appreciating  variations  in  the  intensity  of  the  source  of 
illumination. 

An  instrument  culled  a  photometer  is  employed  for  this  purpose,  and 
consists  essentially  of  an  apparatus — for  example,  the  one  designed  by 
Izard  and  Chibret — by  which  the  intensity  of  two  sources  of  light  may 
be  compared.  The  patient,  looking  into  the  instrument,  sees  two 
equally  bright  disks.  One  disk  is  now  made  darker,  and  the  power  of 
the  eye  to  perceive  the  diHerence  in  the  illumination  of  the  two  disks 
ascertained,  or  one  disk  is  made  entirely  dark,  and  then  gratlually  illu- 
minated, and  the  smallest  degree  of  light  noted  by  which  the  patient 
can  perceive  the  disk  coming  from  the  darkness.  The  former  is  called 
the  light-difference  (L.  D.),  and  the  latter  the  light-fnininium  (L.  M.). 
In  more  exact  language,  to  quote  Percival  Haj'.'  who  has  designed  a 
photometer,  by  light-difference  is  meant  the  minimal  difference  capable 
of  being  perceived — the  threshold  of  discrimination,  and  by  light- 
minimum  is  meant  the  minimal  stimulus  capable  of  being  perceived — 
the  threshold  of  sensibility.  By  means  of  Forster's  photometer  the 
lowest  limit  of  illumination  with  which  an  object  is  still  visible  (the 
minimum  stimulus)  is  ascertained.  The  hght-sense  may  also  be  tested 
with  gray  letters  on  a  white  ground,  those  of  Bjerrum  being  constructed 
on  the  same  principle  as  Snellen's  types.  For  determining  the  "light- 
minimum"  R.  Wallace  Henry's  photometer  is  very  useful.  Ives  and 
H.  Maxwell  Langdon  have  improved  the  accuracy  of  the  last  men- 
tioned instrument  by  using  electricity  with  a  rheostat  and  ammeter  in 
the  circuit  as  the  source  of  illumination,  and  having  the  amount  of 
light  controlled  by  an  iris  diaphragm  instead  of  varying  thicknesses  of 
opal  glass,  as  suggested  by  Henry.  Some  information  in  regard  to  the 
light-sense  may  be  obtained  by  testing  the  acuteness  of  vision  by 
means  of  two  cards,  under  a  different  degree  of  illumination,  and  by 
comparing  the  results  with  a  similar  examination  of  a  subject  believed 
to  have  normal  power  of  appreciating  difierent  degrees  of  illumina- 
tion. De  Wecker's  photometric  types  may  also  be  employeil.  These 
consist  of  white  letters  placed  upon  gray  backgrounds  of  different 
intensities. 

Retinal  Adaptation. — On  passing  from  daylight  into  a  darkenetl 
room  at  first  practically  none  of  the  surrounding  objects  is  visible: 
gradually,  to  use  an  ordinary  expression,  the  eyes  "  become  accustomed 
to  the  darkness"  and  are  able  to  see  more  and  more  distinctly.  Th(> 
complete  adjustment  of  the  eyes  to  the  surrounding  illumination  is 
known  as  (uldptdtion.,  whic^h  takes  place  l)ecause  the  retinal  purple, 
bleached  by  light,  is  regenerated  l)y  degrees.  Adjustment  of  the  eye 
for  the  dark  is  denominatetl  dark-adaptation  or  scoto{)i<i  ami  for  bright 
light — light-adaptation  or  photopia,  using  the  terms  employed  by  Par- 
sons. In  testing  the  light-sense  it  is  necessary  to  allow  a  jieriod  of  time 
for  adaptation  (ten  minutes  is  sufficient  in  ordinary  examinations) 
during  which  the  patient  remains  with  l);in(lMged  eye.s  in  a  dark  room. 
In  place  of  a  photometer,  for  example  Forster's,  an  instrunuMit  known 
'  Aicliivcs  of  ()|)htiiahii(>l(>Ky,  1905,  vol.  xxxiv,  p.  lOO. 


METHOD  OF  HOLMGREN  69 

as  an  adaptometer,  of  which  there  are  several  models,  may  be  advan- 
tageously employed. 

Color=sense. — A  third  subdivision  of  the  sense  of  sight  is  the  color- 
sense,  or  the  power  which  the  retina  has  of  perceiving  color,  or  that 
sensation  which  results  from  the  impression  of  light-waves  having  a 
certain  refrangibiht}'.  This  examination  is  of  especial  interest  in  the 
detection  of  color-blmdness  (see  page  546). 

1.  Method  of  Holmgren. — This  consists  in  testing  the  power 
of  a  person  to  match  various  colors,  convenientl}'  used  in  the  form  of 
colored  yarns.  The  set  of  worsteds  contains  three  large  test-skeins 
namely:  (1)  light  -pure  green,  (2)  rose-purple,  (3)  red;  and  150  small 
skeins  of  the  following  colors:  red,  orange,  yellow,  j-ellow-green,  pure 
green,  blue-green,  blue,  violet,  purple,  pink,  brown,  and  gray.  In  ad- 
dition, there  are  several  shades  of  each  color,  and  a  number  of  grada- 
tions of  each  tint,  from  the  deepest  to  the  lightest.  According  to 
Holmgren,  the  method  of  examination  should  be  as  follows: 

"The  wools  are  placed  in  a  heap  on  a  large  table,  covered  by  a  light  colth  and 
in  broad  dayhght.  A  skein  of  the  test-color  is  taken  from  the  pile  and  laid  far 
enough  awaj'  from  the  others  not  to  be  confounded  with  them  during  the  examina- 
tion. The  person  examined  is  required  to  select  other  skeins  from  the  pile  nearly 
resembling  it  in  color,  and  to  place  them  bj-  the  side  of  the  sample.  He  is  made 
thoroughh'  to  understand  that  he  is  required  to  search  the  heap  for  the  skeins 
which  make  an  impression  on  his  chromatic  sense,  and  quite  independently  of  any 
name  he  may  give  the  color  similar  to  that  made  by  the  test-skein.  The  examiner 
should  explain  that  resemblance  in  every  respect  is  not  necessary;  that  there  are 
no  two  specimens  exacth'  ahke;  that  the  onh-  question  is  the  resemblance  of  the 
color,  and  that,  consequenth-,  the  candidate  must  endeavor  to  find  something 
similar  in  shade,  something  hghter  and  darker  of  the  same  color,  etc. 

"Test  I. — The  green  test-skein  is  presented.  The  examination  must  con- 
tinue until  the  candidate  has  placed  near  the  test-skein  all  the  other  skeins  of  the 
same  color;  or  else,  with  these  or  separately,  one  or  more  of  the  skeins  of  the  class 
of  confusion  colors,  or  until  he  has  slifficienth*  proved,  b}-  his  manner,  that  he 
can  easily  and  unerringly  distinguish  the  confusion  colors,  or  gives  unmistakable 
proof  of  a  difficulty  in  accomplishing  it.  The  candidate  who  places  with  the  test- 
skein  confusion  colors  (gray,  drab,  fawn,  hght  pink  or  yellow)— that  is  to  say, 
finds  that  they  resemble  the  test-color — ^is  color-blind;  while  if  he  evinces  a  manifest 
disposition  to  do  so,  though  he  does  not  absolutely  do  so,  he  has  a  feeble  chromatic 
sense. 

"Test  II. — The  rose-purple  skein  is  presented.  The  examination  must  con- 
tinue until  the  candidate  has  placed  all  or  the  greater  part  of  the  skeins  of  the 
same  shade  near  the  sample;  or  else,  simultaneously  or  separately,  one  or  more 
skeins  of  the  confusion  colors.  If  he  confuses  the  colors,  he  will  select  either  the 
light  or  deep  shades  of  blue  and  violet,  especially  the  deep,  or  the  hght  and  deep 
shades  of  one  kind  of  green,  or  gray  inclining  to  blue.  A  candidate  who  is  proved 
color-bhnd  bj-  the  first  test,  and  who  in  the  second  test  selects  only  purple  skeins, 
is  incompletely  color-blind.  If  in  the  second  test  he  selects  with  the  purple  blue  or 
violet,  or  one  of  them,  he  is  completely  red-blind.  If  in  the  second  test  he  selects 
with  purple  only  green  or  gray,  or  one  of  them,  he  is  completely  green-blind.  The 
red-bhnd  never  select  the  colors  taken  by  the  green-blind,  and  vice  versa.  The 
green-blind  will  often  place  a  violet  or  blue  skein  by  the  side  of  the  green,  but  it  will 
then  only  be  the  brightest  of  these  colors. 

"Test  III. — The  red  skein  is  presented.  The  test,  which  is  appUed  to  those 
completely  color-blind,  should  be  continued  until  the  person  examined  has  placed 
beside  the  test-skein  all  the  skeins  belonging  to  this  hue,  or  the  greater  part,  or 


70     EXTERNAL  EXAMINATION  OF  THE  EYE — FUNCTIONAL  TESTING 

else  one  or  more  confusion  colors.  The  red-blind  chooses  besidef!  the  red,  green, 
and  shades  of  brown,  wliich,  to  the  normal  sense,  seem  darker  than  red.  On  the 
other  hand,  the  green-blind  selects  shades  of  these  colors  which  appear  lighter 
than  red. 

"The  absence  of  all  except  one  color  sensation  {monochromatic  vision)  will  be 
recognized  by  confusion  of  every  hue  having  the  same  intensity  of  hght.  Violet- 
blindness  will  be  recognized  by  a  genuine  confusion  of  purple,  red,  and  orange  in 
the  second  test." 

This  tost  in  use  for  many  years  is  obviously  unsatisfactory  in 
several  particulars  and  has  been  largely  replaced  by  other  methods. 

Jennimjs'  Self  Recording  Test  is  virtually  the  Holmgren  test  ar- 
ranged in  a  different  form,  with  small  patches  of  colored  worsteds,  so 
placed  that  they  are  protected  from  dust  and  light  and  the  candidate 
makes  his  own  record  as  the  examination  proceeds  by  pricking  the 
record  sheet  with  a  stj'lus  or  pointed  pencil.  Jennings'  test  was  the 
official  test  for  color  blindness  in  the  medical  service  of  our  army 
aviation  corps  during  the  war  and  was  found  to  be  convenient  and 
satisfactory. 

2.  Method  of  Thomson. — The  late  Dr.  "William  Thomson  de- 
vised the  following  arrangement  of  the  yarns: 

The  set  consi.sts  of  a  large  green  and  a  large  rose  test-skein,  and  40  small  skeins, 
each  marked  with  a  bangle  having  a  concealed  number,  extending  from  1  to  40, 
placed  in  a  double  box,  so  arranged  as  to  keep  the  two  series  apart. 

The  large  green  skein  being  placed  near  b}',  the  small  skeins  from  1  to  20  are 
placed  in  good  daylight,  and  the  employee  under  examination  is  directed  to  select 
10  shades  of  the  same  color  as  the  test-skein.  One  with  normal  vision  will  choose 
promptly  the  10  greens  with  odd  numbers. 

A  color-blind  person  will  hesitate,  and  his  selections  will  contain  some  even 
numbers,  and  the  confusion  colors  will  be  shades  of  brown,  etc.,  containing  some 
red,  or  shades  of  gray,  and  will  indicate  the  color  defect.  These  figures  are  to  be 
recorded  on  a  blank,  and  the  20  skeins  are  to  be  removed.  The  large  rose  skein 
is  then  used,  and  the  examination  repeated  in  like  manner  with  skeins  numbered 
from  21  to  40,  and  the  result  recorded.  The  confusion  skeins,  which  have  even 
numbers,  are  blue,  green,  and  gray.  From  the  selections  made  by  the  man  found 
color  defective  by  the  green  test  we  are  able  to  decide  the  character  of  his  color- 
blindness. Those  selecting  blues  are  red-blind,  those  taking  greens  and  grays  are 
green-blind,  according  to  the  nomenclature  of  Holmgren.  There  are  10  roses  and 
10  confusion  colors  in  the  second  series. 

3.  The  Lantern  Test. — To  control  and  also  to  substitute  the 
various  wool-tests,  lanterns  for  detecting  color-blindness  are  employed. 
Useful  models  have  been  designed  by  William  Thomson,  Charles  H. 
Williams,  and  Edridge-Cin-en.  ConcerninL^  lantern  tests,  Dr.  Tlu»ni- 
son  wrote  as  follows:  "Whilst  the  wool-tests  have  been  accepted 
universally  as  recjuisite  for  the  detection  of  color  defects,  the  employees 
of  railroads  and  their  friends  have  always  objected  to  their  use  as 
having  no  relation  to  their  daily  duties,  and  have  diMuanded  such 
colors  as  are  employed  as  signals,  l-'urtherniore,  for  two-fifths  of  the 
time  during  tiie  night  of  an  employee's  life  he  is  expected  to  govern  his 
actions  by  colored  lights,  and  hence  a  lantern  which  can  imitate  the 
night  signals  in  form,  color,  intensity',  and  size,  as  the}'  appear  under 


THE    PSEUDO-ISOCHROMATIC    PLATES    OF    STILLING  71 

all  obstructions  caused  by  rain,  snow,  fog,  and  smoke,  is  desirable. 
Its  power  over  the  wools  to  detect  the  central  amblyopias  of  tobacco, 
alcohol,  drugs,  and  disease,  that  would  not  be  revealed  by  the  skeins, 
make  it  a  necessity." 

Dr.  Thomson  described  his  lantern  as  follows:  "It  consists  of  an  asbestos  chim- 
ney, which  can  be  placed  on  the  kerosene  lamp  in  universal  use  on  railroads,  or, 
over  an  Argand  or  other  gas  light,  electric  lamp,  or  spring  candle-stick.  Two  disks 
4  inches  in  diameter,  are  so  placed  upon  the  chimney  as  to  permit  of  their  being 
superimposed  pa^tl3^  The  low-er  disk  contains  seven  glasses  in  apertures  3-2  inch 
in  diameter,  having  the  w^hite,  red,  green,  and  blue  colors  in  general  use  on  rail- 
roads. This  may  be  considered  the  'examination  in  chief,'  whilst  the  upper  disk, 
when  combined  with  the  lower  by  turning  one  or  both,  furnishes  the  'cross-examin- 
ation.' The  upper  disk  has  two  apertures,  one  '-i  2  inch,  the  other  H  inch,  with 
white  glass.  The  other  five  have  one  white  ground  glass,  one  deep  London  smoke, 
one  pink,  one  green,  and  one  cobalt-blue  glass. 

"The  combination  of  the  white  ground  and  the  smoke  glass  with  the  reds  and 
greens  of  the  low^er  disk  enables  all  atmospheric  conditions  to  be  imitated,  and  the 
lights  to  be  diminished  in  brightness  and  tint.  The  use  of  the  small  opening  enables 
size  and  distance  of  signals  to  be  imitated. 

"The  standard  for  color-sense  is  taken  as  an  opening  of  3i  2  inch  at  20  feet.  A 
man  failing  to  see  the  colored  light  at  this  distance  may  have  it  increased  ten  times 
=  ^^200  by  using  the  large  openings.  Again  failing,  he  may  approach  to  1  foot  and 
reveal  a  color-sense  equal  to  Moo  only.  The  resemblance  to  the  tests  for  form  by 
Snellen's  letter  is  to  be  noted.  Since  the  color-blind  depend  alone  on  intensity  of 
brightness  to  distinguish  the  white,  green,  and  red  signals,  the  diminishing  effect  of 
the  ground  glass  and  of  the  London  smoke  often  reveals  the  defect.  The  cobalt, 
transmitting  blue  and  red  both,  is  usually  described  by  the  color-blind  as  blue, 
which  color  thej^  always  see  well,  being  blind  for  red.  The  cobalt,  combined  with 
the  lower  reds,  gives  a  very  deep  red  color,  which,  when  compared  with  the  usual 
red,  may  induce  the  color-bhnd  to  name  one  red,  the  other  green.  Combined 
with  the  lower  blue  it  gives  a  deep  pink,  called  blue  by  the  color-blind. 

"In  the  pink,  London  smoke,  and  light  green  glasses  in  the  upper  disk  I  have 
imitated  the  'confusion  colors.'  The  pink  looks  cherry  red  to  the  normal  e3^e,  but 
it  transmits  both  red  and  blue  by  the  spectroscope,  hence  the  color-blind  pronounce 
it  blue,  or,  when  backed  bj^  a  j^ellow  flame,  white.  The  hght  green  is  also  called 
white,  as  is  also  the  hght  gray  of  the  London  smoke.  Hence  we  have  in  these  three 
glasses  tints  which  the  color-bhnd  name  white,  and  reveal  their  defect  therebj-. 

"The  upper  disk  has  its  seven  openings  marked  by  the  letters  of  the  alphabet, 
and  the  lower  by  the  numerals  from  one  to  seven.  The  examination  should  be 
made  in  a  darkened  room,  and  the  results  reported  on  a  blank,  the  details  being 
used  when  requisite.  The  man  examined  is  expected  to  call  or  name  the  colors 
and  to  recognize  them  at  20  feet." 

4.  The  Pseudo=isochromatic  Plates  of  Stilling. — These  consist 
of  a  series  of  plates  (10  in  number),  each  plate  containing  4  squares 
filled  by  small,  irregular,  colored  spots,  among  -which  other  spots  in  a 
confusion  color,  made  to  conform  to  an  i^rabic  figure,  are  placed.  The 
test-plate  is  held  in  a  good  light,  and  the  examiner  requires  the  subject 
to  distinguish  the  tracings.  Dr.  Shinobu  Ishihara  of  Tokyo,  on  the 
same  principle  as  the  Stilling  tests  has  constructed  a  convenient 
series  of  plates  for  testing  color  bHndness. 

Nagel's  Caed  Test. — This  test  consists  of  a  set  of  cards  on  each 
one  of  which  a  series  of  colored  disks  arranged  in  a  ring  is  placed.  On 
some  of  the  cards  all  of  the  disks  are  of  one  color;  on  others  the  disks 


72     EXTERNAL  EXAMINATION  OF  THE  EYE — FUNCTIONAL  TESTING 

are  of  two  or  three  different  colors,  that  is,  confusion  colors.  The 
cards  being  displayed  in  a  good  light  the  candidate  is  required  to  state 
which  rings  are  monochromatic  and  is  next  recjuired  to  select  in  the 
dichromatic  or  trichomatic  rings  all  of  the  disks  wliich  are  of  one 
special  color.  The  results  demonstrate  whether  the  candidate  is  color- 
bhnd  and  also  to  which  class  of  the  color-blind  he  belongs. 

While  no  single  test  for  color-blindness  is  infallible  good  results 
can  with  care  be  obtained.  Parsons  believes  that '"a  properly  con- 
structed lantern  will  eliminate  all  bad  cases."  Duane  recommends 
Nagel's  or  Stilling's  test,  supplemented  by  the  lantern  test  as  the  most 
satisfactory  means  of  detecting  color-blindness.  In  this  country  in 
practical  work  a  combination  of  the  wool  and  lantern  tests  is  com- 
monly applied;  certainly  the  wools  should  not  be  used  to  the  ex- 
clusion of  other  tests,  especially  those  which  include  a  suitable 
lantern. 

5.  Special  Tests. — These  include  the  use  of  the  spectroscope  and 
various  forms  of  chromatometers,  for  example,  the  chromatophotometer 
of  Chibret.  For  an  SLCCurate  dctennination  i\  agel's  anomaloscope  may 
be  employed.  The  instrument  consists  essentially  of  a  mounted  tele- 
scope tube  into  which  the  observer  looks  and  sees  two  semicircles,  one 
illuminated  with  sodium  yellow  and  the  other  either  with  lithium  red. 
or  thallium  green,  or  a  mixture  of  red  and  green.  The  color  inten- 
sities can  be  varied  by  a  measured  amount  antl  those  used  to  make  a 
match  between  the  two  semicircles  indicate  the  character  of  the  parti- 
cular color  sense. 

Direct  vision  for  colors  may  be  studied  by  i)la('ing  the  patient  at  a 
given  distance  from  a  chart  or  disk  of  graduated  colors,  and  noting  the 
amount  of  surface  exposure  which  is  required  for  the  color  to  be  pro- 
perly recognized.  In  the  scale  of  De  Wecker  and  Masselon  the  colored 
surface,  2  cm.  square,  should  be  recognized  at  5  meters;  that  is.  the 
chromatic  vision  or  V.C.  or  C.  =  1;  if  a  colored  test  must  be  four 
times  this  size  in  order  to  be  recognized,  C  =  }i,  etc.  Snydacker 
affixes  to  the  ordinary  type  card  squares  of  red  (2.5  and  5  mm.  in  size) 
and  green  (3  and  6  mm. in  size),  the  test  being  made  at  G  meters. 
P'ailure  to  differentiate  the  larger  test  objects  suggests  the  need  of 
perimetric  examination;  also  central  scotomas  for  rcnl  and  giecn  may 
be  thus  rapidly  detected  (see  page  89). 

Accommodation  has  been  defined  to  be  those  changes  in  the 
optical  adjustment  of  the  eye  effected  by  llu'  ciliary  muscle,  and  in 
practice  is  measured  by  finding  llie  nearest  point  at  which  line  print  can 
be  clearly  deciphered,  or  by  Duane's  test  (see  page  39).  The  typo 
usually  adopted  is  that  known  as  Snellen's  0.5  or  Jager's  1  (^see  also 
page  37). 

In  order  to  study  the  ijheiiomena  of  accommodation  the  student 
should  record:  (1)  The  ne.-irest  i)oint  of  perfectly  ilistinct  vision  attain- 
able with  the  smallest  readable  type,  or  the  punctuni  proxii/tmn  (abbre- 
viated p.  p.,  or  simply  p.).  (2)  The  fartliest  point  of  distinct  vision,  or 
punctuni  reniotum   (abbreviated  p.  r.,  or  simply  /.).      (3)  Tiie  range, 


BALANCE  OF  THE  EXTERIOR  EYE  MUSCLES        73 

amplitude  of  accommodation,  or  the  expression  of  the  amount  of 
accommodative  effort  of  which  the  eye  is  capable.  This  is  expressed 
in  the  number  of  that  convex  lens,  placed  close  to  the  cornea,  whose 
focal  length  equals  the  distance  from  the  near  point  to  the  cornea,  and 
which  gives  rays  a  direction  as  if  they  had  come  from  the  far  point; 
thus,  if  the  near  point  be  7  cm.,  the  lens  which  expresses  the  amplitude 

of  accommodation  is  +  14D  -—  =  14.     (4)  Relative  accommodation,  or 

that  independent  portion  of  this  function  which  can  be  exercised  with- 
out alteration  in  a  given  amount  of  convergence,  and  which  is  divided 
into  a  negative  portion,  or  that  portion  which  is  already  in  use,  and 
a  positive  portion,  or  that  portion  which  is  not  in  use  (see  also  pages 
35  and  46). 

Mobility  of  the  Eyes. — This  is  tested  by  causing  the  patient  to 
follow  with  his  eyes,  the  head  remaining  stationary,  the  movements 
of  the  uplifted  finger,  which  is  directed  to  the  right,  to  the  left,  upward 
and  downward;  or,  better,  a  small  electric  light,  the  reflections  of  which 
from  the  corneas  can  be  noted.  Both  eyes  must  be  observed,  and  note 
made  of  any  lagging  in  their  movements,  or  of  the  failure  of  either  eye 
readily  to  turn  into  the  nasal  or  temporal  canthus.  At  the  saine  time 
the  relation  of  the  movements  of  the  upper  lid  to  those  of  the  eyeball 
is  recorded.  The  attention  of  the  patient  must  be  centered  upon  the 
moving  test,  and  allowance  should  be  made  for  the  imperfect  mobility 
of  highly  myopic  eyes.  Any  asymmetry  of  the  skull  or  difference  in 
the  level  of  the  two  orbital  margins  may  be  observed,  because  such 
conditions  are  not  infrequently  associated  with  ametropic  eyes, 
especially  where  the  two  eyes  possess  great  inequahty  in  refractive 
conditions.  (For  accurate  determination  of  ocular  rotations  see 
page  575,  and  Appendix,  page  766.) 

Balance  of  the  Exterior  Eye  Muscles. — Under  normal  condi- 
tions perfect  equilibrium  of  the  exterior  eye  muscles  is  present,  and 
there  is  no  interference  with  binocular  fixation  and  binocular  single 
vision  (see  page  574).  Under  abnormal  conditions  the  movements  of 
the  eyes  may  be  deranged  so  that  one  eye  deviates,  or  tends  to  deviate, 
from  the  point  of  fixation — that  is,  from  the  object  which  it  is  regard- 
ing.    These  deviations  may  be  classified  thus: 

1.  Manifest  deviation — that  is,  a  deviation  of  an  eye  which  the 
patient  cannot  overcome.  This  is  known  as  strabismus,  squint,  or 
heterotropia,  and  is  fully  considered  on  pages  576  and  609. 

2.  Latent  deviation — that  is,  a  tendency  of  the  visual  line  to  deviate 
from  the  point  of  fixation.  This  tendency,  however,  is  overcome  by  a 
muscular  effort,  owing  to  the  stimulus  which  the  eyes  always  have  to 
maintain  binocular  single  vision.  It  is  generally  described  by  the 
term  latent  squint,  suppressed  squint,  or  heterophoria.  It  is  frequently 
designated  insufficiency  of  the  ocular  muscles,  and  was  called  by  von 
Graefe  dynamic  strabismus  (see  page  609). 

According  to  G.  T.  Stevens,  the  various  conditions  of  equilibrium 
or  variation  from  it  may  be  arranged  in  four  classes : 


74     EXTERNAL  EXAMINATION  OF  THE  EYE  —FUNCTIONAL  TESTING 

L  Orthophoria,  a  tending  of  the  vi.«ual  lines  in  parallelism. 

2.  Heterophoria,  a  tending  of  the  visual  lines  in  some  other  direction,  but  with 
abilit}-  to  adjust  them  habitually  for  single  vision. 

3.  Heterotropia,  a  deviation  of  the  visual  lines  from  paralleli-sm  in  such  manner 
that  they  cannot  habitually  be  united  at  the  same  point  of  fixation. 

4.  Armtropia,  kalotropia;  or  anophoria,  katophoria — variations  from  equilibrium 
which-  may  or  may  not  be  consistent  with  parallelism  of  the  visual  hnes,  but  in 
which,  with  the  least  innervation  of  the  eye  muscles,  the  visual  lines  of  both  eyes 
would  fall  l)elow  (katotropia)  or  ris(>  above  (anotropia)  the  most  favorable  plane 
for  the  minimum  effort.  Thus  with  ano-  or  katotropia  there  may  be  associated 
heterophoria  or  heterotropia. 

Heterophoria  may  be  divided  into  the  following  speci6c  conditions: 

1.  Esophoria,  a  tending  of  the  visual  lines  in\%ard. 

2.  Exophoria,  a  tending  of  the  visual  lines  outward. 

3.  Hyperphoria  (right  or  left),  a  tending  of  the  visual  line  of  one  eye  (right  or 
left)  in  a  direction  above  its  fellow,  constituting,  as  the  case  may  be,  right  or  left 
hyperphoria. 

The  term  does  not  imply  that  the  line  to  which  it  is  referred  is  too  high,  but 
that  it  tends  higher  than  the  other,  without  indicating  which  ma}-  be  at  fault. 
The  compound  tendencies  are: 

1.  Hyper  esophoria  (right  or  left),  a  tendency  of  one  visual  line  to  rise  above  the 
other,  with  a  tendency  also  of  the  lines  inward. 

2.  Hyper  exophoria  (right  or  left),  a  tendency  of  one  visual  line  to  rise  above  the 
other,  with  a  tendency  also  outward. 

Heterotropia  may  be  divided  into  two  subclasses: 

(a)  Deviations  consistent  with  a  physiologic  state  of  the  muscles  and  nervi^s, 
as  in  the  ordinary  concomitant  squint. 

{h)  Deviations  resulting  from  pathologic  conditions — as,  for  example,  devia- 
tions from  paralysis  or  from  mechanical  causes. 

The  specific  divisions  of  the  subclass  (a)  are: 

1.  Esotropia,  a  deviation  of  the  visual  lines  inward. 

2.  Exotropia,  a  deviation  of  the  visual  lines  outward. 

3.  Hypertropia  (right  or  left),  a  deviation  of  one  visual  line  above  the  other. 

4.  Hyper  esotropia  and  hyperexotropia  are  the  compound  deviations. 
Cyclophoria  is  a  term  introduced  by  Savage  to  describe  want  of  equiUbrium  of 

the  oblique  muscles. 

In  order  to  ascertain  the  condition  of  the  ocular  niusclos  the  follow- 
ing te-sts  are  employed: 

1.  The  Screen  (Cover)  and  Parallax  Tests. — Require  the  patient 
to  regard  a  small  point  of  light  upon  a  lilack  background  5  or  (>  meters 
distant,  or  a  round  black  spot  I  inch  in  diameter  in  the  center  of  a  white 
card-board  at  a  similar  distance.  Cover  the  left  eye  with  a  screen, 
making  sure  that  the  patient  is  fixating  the  test-object  with  his  right 
eye.  Pass  the  screen  rapidly  from  tiie  left  to  the  right,  and  observe 
the  movements  of  the  eye  which  take  place  beiiind  the  cover.  Out- 
ward deviation  indicates  exophoria;  inward  deviation,  esophoria; 
vertical  deviation,  hyperphoria.  The  prism,  placed  base  inward, 
which  neutralizes  the  outwai'd  deviation  is  a  measure  of  the  exophoria; 
tlic  prism,  placed  i)ase  outward,  wliich  neutralizt^s  the  inward  de\iatiou 
is  a  measure  of  the  esopiioria;  the  prism,  placed  base  up  or  base 
down,  which  neutralizes  the  vertical  deviation  is  a  metisure  of  the 
hyperplioria. 

Wliile  the  screen  is  being  moved  rapidly  from  one  eye  to  the  otlier 
request  the  patient  to  describe  the  a|)parent  movement  of  the  test- 


I 


BALANCE  OF  THE  EXTERIOR  EYE  MUSCLES         75 

object.  If  this  moves  in  the  same  direction  in  which  the  cover  is 
moved,  exophoria  is  inchcated;  if  in  the  opposite  direction,  esophoria; 
if  upward  or  downward,  hyperphoria.  These  apparent  movements 
may  be  neutrahzed  as  before  with  appropriately  placed  prisms. 
Require  the  patient  to  fix  upon  a  fine  object,  as  a  pencil-point,  held 
below  the  horizontal,  20  or  25  cm.  from  the  eye,  and,  in  order  to  remove 
the  control  of  binocular  vision,  cover  one  eye  with  a  card  or  the  hand, 
and  observe  whether  the  eye  under  cover  deviates  inward  or  outward, 
upward  or  downward,  and  returns  to  fixation  when  the  cover  is 
removed,  and  neutralize  the  movement  with  appropriately  placed 
prisms. 

2.  Prism  Tests. — A  small  flame  is  placed  against  a  dark  back- 
ground at  5  or  6  meters  from  the  patient,  and  on  a  level  with  his  eyes. 
In  an  accurately  adjusted  trial-frame  a  prism  of  7°  is  inserted,  base 
down,  before  one  eye — for  example,  the  right.  Vertical  diplopia  is 
induced,  and  the  upper  image  belongs  to  the  right  eye.  If  the  flames 
stand  one  directly  over  the  other,  there  is  no  incUnation  to  divergence 
or  convergence.  If  the  upper  image  stands  to  the  left,  there  is  exo- 
phoria; if  to  the  right,  esophoria.  That  prism  placed  with  its  base 
in  or  out  before  the  left  eye,  according  to  circumstances,  which  brings 
the  two  images  into  a  vertical  hne,  measures  the  degree  of  the 
deviation. 

In  order  to  test  the  functions  of  the  vertical  muscles  at  a  distance 
of  6  meters  the  patient  is  seated  as  before,  and  a  prism  of  sufficient 
strength  to  induce  homonymous  diplopia  is  placed  before  one  eye, — 
for  example,  the  right, — i.  e.,  with  its  base  toward  the  nose.  If  the 
images  are  on  the  same  level,  no  deviating  tendency  is  present.  If,  for 
example,  the  right  image  rises  higher  than  the  other,  the  visual  hne  of 
the  right  eye  tends  to  be  lower  than  that  of  its  fellow,  and  there  is 
hyperphoria.  That  prism,  placed  with  its  base  down  before  the  left 
eye,  which  restores  the  images  to  the  horizontal  level,  measures  the 
degree  of  deviation. 

3.  Equilibrium  Test. — In  order  to  test  the  functions  of  the  lateral 
muscles  at  the  ordinary  working  distance,  or  30  cm.,  it  is  customary  to 
employ  the  equilibrium  test  of  von  Graefe,  in  which  a  card,  having 
upon  it  a  large  dot,  through  which  a  fine  line  is  drawn,  is  held  25  or 
30  cm.  from  the  eyes,  diplopia  being  induced  by  means  of  a  prism  of  10°, 
base  up  or  down,  before  one  eye.  A  more  accurate  test-object  is  a  small 
dot  and  fine  line,  or  a  singe  word  printed  in  fine  type,  requiring  accurate 
fixation  and  a  sustained  effort  of  accommodation.  If,  the  prism  being 
placed  base  down  before  the  right  eye,  the  images  stand  exactly  one 
above  the  other,  equilibrium  is  evident;  if  the  upper  image  (image  of 
the  right  eye)  stands  to  the  left  of  the  lower  image,  there  is  crossed 
lateral  deviation;  and  that  prism,  placed  before  the  left  eye  with  its 
base  toward  the  nose,  which  restores  the  images  to  a  vertical  line, 
measures  the  tendency  to  divergence  or  exophoria.  If  the  upper 
image  stands  to  the  right  of  the  lower,  there  is  homonymous  lateral 
deviation;  and  that  prism,  placed  before  the  left  eye  with  its  base  toward 


76     EXTERNAL  EXAMINATION  OF  THE  EYE — FUNCTIONAL  TESTING 


the  temple,  which  restores  the  images  to  a  vertical  line,  measures  the 
tendency  to  convergence  or  esophoria.  The  vertical  muscles  should 
also  be  tested  at  the  ordinary  working  distance  with  a  prism  placed 
before  one  eye,  with  the  base  before  the  nose,  as  already  described 
above. 

Edward  Jackson's  test  for  muscle  balance  at  the  working  distance 
is  useful.  It  consists  of  a  small  white  square  on  a  black  ground,  which 
is  held  at  a  distance  of  33  cm.  from  the  eyes,  and  which  is  regarded 
through  a  strong  convex  cylinder  (10  or  12  D)  placed  before  one  eye. 
The  white  spot  appears  as  a  gray  streak,  which  seems  to  pass  through 
the  spot  if  there  is  orthophoria,  but  to  one  or  other  side  of  it,  or  above 
or  below  it,  if  there  is  heterophoria.  The  axis  of  the  cyUnder  must  be 
vertical  to  test  the  vertical  balance,  and  horizontal  to  test  the  lateral 
balance.  The  Maddox  rod  test  (see  page  79)  has  also  been  adapted  to 
the  working  distance,  the  test-object  being  a  small  illuminated  square 
on  a  black  ground,  which  is  viewed  at  the  near  point  through  a  Maddox 
rod.     Schild  and  B.  F.  Baer,  Jr.  have  designed  useful  instruments. 

4.  In  order  to  test  the  convergence  near  point,  approach  a  finger  or 
pencil  to  the  nearest  point  upon  which  the  oyos  can  converge.  This 
should  be  situated  at  no  greater  distance  that  8  cm.  (3^2  inches)  from 
the  eyes — that  is,  2.5  to  4.5  cm.  (  1-1/-^  inches)  from  the  nose.  If, 
before  this  point  is  reached,  outward  deviation  of  one  eye  occurs,  the 
amount  of  convergence  is  deficient  (see  also  page  574). 

5.  In  order  to  ascertain  the  power  of 
adduction  (properly  prism-cojicergence), 
abduction  (properly  prism-divergence),  and 
sursumduction  isursumvergence) ,  the 
strongest  prism  which  the  lateral  and 
vertical  muscles  can  overcome  is  found 
(see  page  575).* 

Beginning  with  adduction  (prism-con- 

tergence),  find  the  strongest  prism  placoil 

before  one  eye,  with  its  base  toward  the 

temple,    through    which    the    flame    stil! 

remains   single.     The    test   should    begin 

with  a  weak  prism,  the  strength  of  whicli 

is  gradually  increased  until  the  limit  is  ascertained.     This  varies  from 

30*^    to   ()0°,   the    higher   d('gre(>s,   however,   in   most  instances  being 

attained  only  after  a  reasonai)le  degree  of  practice. 

In  like  manner  aJbdnctioti  (prism-divergence)  is  tested,  the  prism 
now  being  turned  with  its  base  toward  the  nose;  G°  to  8®  of  prism 
should   be  overcome.     The   ratio  between   adihiction   and   abduction 


Fig.  32.      Ris 


rotary  ijnsm. 


'  According  to  Duane,  the  term  "iiddiiction  "  is  proiu'rly  ."ippliod  imly  to  the 
aniount  (40°-.'J0°)  hy  which  earh  vyv  can  turn  iiiw.nrti  when  iiioviiij!;  pjirallol  with 
its  fcll<nv  {(iii!<(ici(U(<{  (uiiluction,  or  adduction  proj)fr);  "aliduction,"  to  the  absohitc 
degree  of  rotation  of  each  eye  outward  in  performing  assi)ciated  parallel  movements, 
whicli  is  •10°-50°;  "sursumduction,"  to  the  alisolutt*  ilegree  of  movement  of  I'ither 
eye  upward — a  movement  of  .some  -10"  in  extent. 


k 


BALANCE  OF  THE  EXTERIOR  EYE  MUSCLES         77 

should  be  6  to  1  (Stevens) — i.  e.,  if  adduction  is  48°,  abduction  should 
be  8°;  but,  according  to  Risley,  in  carefully  corrected  or  emmetropic 
eyes,  the  ratio  is  3  to  1.  Banister  found  the  primary  adduction  for  6 
meters  to  be  only  14°.  As  Hansell  and  Reber  properly  observe,  no 
arbitrary  standard  of  the  ratio  between  prism-convergence  and  prism- 
divergence  can  be  given,  although  the  latter  is  fairly  constant  under 
normal  conditions. 

Sursumdndion  (sursumvergence) ,  or  the  power  of  uniting  the  image 
of  the  candle-flame,  seen  through  a  prism  placed  with  its  base  down- 
ward before  one  eye,  with  the  image  of  the  same  object  as  seen  by  the 
other  eye,  is  ascertained  by  beginning  the  trial  with  a  weak  prism,  ^^° 
or  1°,  and  gradually  increasing  its  strength.  The  limit  is  usually  2°, 
but  may  be  as  high  as  6°  or  8°.  Right  sursumvergence  is  equivalent  to 
the  degree  of  that  prism  placed  base  down  before  the  right  eye  Cor  base 
up  before  the  left),  and  left  sursumiergence  to  the  degree  of  that  prism 
placed  base  down  before  the  left  eye  (base  up  before  the  right)  through 
which  the  test-object  still  remains  single.  Right  and  left  sursumver- 
gence are  normally  equal. 


Fig.  33. — Stevens'  phorometer. 

If  the  eyes  of  the  patient  under  examination  are  ametropic,  the 
proper  correcting  lenses  should  be  placed  before  them,  and  the  ex- 
amination for  the  various  forms  of  heterophoria  made  through  this 
glass,  which  should  be  accurately  centered. 

Practically  all  the  examinations  for  muscular  errors  can  be  made 
with  a  series  of  prisms  and  a  trial-frame,  but  they  are  facilitated  by 
the  use  of  certain  instruments  of  precision,  especially  some  form  of 
Herschel  or  revolving  prisrn,  the  one  devised  by  Risley  being  the  best. 
The  latter  consists  of  two  prisms,  superimposed  with  their  bases  in 
opposite  directions;  constituting  a  total  value  of  45°.  They  are  mounted 
in  a  cell  which  has  a  delicately  milled  edge,  and  fits  in  the  ordinary 
trial-frame.  The  milled  edge  permits  convenient  turning  in  the  frame, 
so  that  the  base  or  apex  of  the  prisms  can  be  readily  placed  in  any  de- 
sired direction.  The  prisms  are  caused  to  rotate  in  opposite  directions 
by  means  of  a  milled  screw-head,  projecting  from  the  front  of  the  cell. 
With  this  rotary  prism  the  strength  of  the  abducting,  adducting,  and 
supra-  and  infraducting  muscles  can  be  measured.     If  the  rotary  prism 


78     EXTERNAL  EXAMINATION  OF  THE  EYE  —FUNCTIONAL  TESTING 


is  placed  before  the  left  eye  with  the  zero  mark  vertical  and  the  screw 
turned  to  the  right  or  left,  it  will  cause  the  base  of  the  resultinc  prisms 
to  be  either  inward  or  outward — that  is,  toward  the  nose  or  temple,  as 
may  be  desired;  or  it  may  be  placed  with  the  zero  mark  horizontal,  and 
the  base  turned  upward  or  downward.  All  examinations  for  muscular 
defects  may  be  made  with  a  -phorometer.  A  number  of  excellent 
models  are  available. 

6.  Obtuse-angled  Prism  Test. — One  of  the  simplest  tests  of  the 
ocular  muscles  is  the  obtuse-angled  prism  of  Maddox.  This  is  composed 
of  "two  weak  prisms  of  3°  united  by  their  bases. 
On  looking  through  the  line  thus  formed  at  a  dis- 
tant flame,  two  false  images  of  it  are  seen,  one  higher 
and  one  lower  than  the  real  image  seen  by  the  other 
ej-e,  the  position  of  which,  to  the  right  or  the  left 
oi  the  line  between  the  false  images,  indicates  the 
equilibrium  of  the  eye.  A  faint  band  of  light,  of 
the  same  breadth  as  the  two  false  images,  is  seen 
extended  between  them"  (Fig.  34).  The  answers 
of  the  patient  may  be  materially  assisted  by  placing 
a  red  glass  before  one  eye,  and  thus  tinting  the  real 


Fn!.  ;i4.  —  Position 
of  the  images  as  seen 
throuKli  the  ohtuse- 
anKled  prism  of  Mail- 
dox. 


Fig.  '.i'). — Tests  for  insufficiency  of  oblique  muscles ^ 
1,  InsufTiciency  of  left  superior  ohlitiue;  2,  insufliciency 
of  left  inferior  ohliiiuo;  .'{,  iiisuffiiiency  of  riRht  superior 
obli<iue;  4,  insufiiciency  f)f  rij;ht  inferior  oMitjue;  5,  equi- 
librium of  obli(iue  muscles  (Savage). 


image.  If  this  stands  directly  in  the  center  between  the  two  false  im- 
ages, all  f(jrMi,s  iA  latent  deviation  are  eliminated;  if  it  stands  to  the 
right  or  to  the  left,  there  is  exo])horia  or  e.sophoria;  if  it  stands 
above  or  below  the  center,  or  is  fused  with  either  the  upper  or  the 
lower  image,  there  is  hyperphoria. 

7.  Insufficiency  of  the  oblique  muscles  (r!i<'Ioj)hori(i),  acct)rcling  to 
Savage,  may  bf  dctfclfd  "by  placing  a  Maddox  prism,  with  its  axis 


BALANCE  OF  THE  EXTERIOR  EYE  MUSCLES 


79 


vertical,  before  one  eye,  the  other  being  covered,  which  regards  a 
horizontal  hne  on  a  card  18  inches  distant.  This  Hne  appears  to  be 
two,  each  parallel  with  the  other.  The  other  eye  is  now  uncovered, 
and  a  third  line  is  seen  between  the  other  two,  with  which  it  should  be 
parallel.  Want  of  harmony  in  the  oblique  muscles  is  shown  by  want  of 
parallelism  of  the  middle  with  the  other  two  lines,  the  right  end  of  the 
middle  hne  pointing  toward  the  bottom  and  the  left  end  toward  the 
top  line,  or  vice  versa,  depending  upon  the  nature  of  the  case"  (Fig.  35). 

8.  Cobalt  Test. —  A.  trial-frame  armed  on  one  side — for  example,  the 
right — with  a  piece  of  cobalt  glass  is  placed  in  position  and  the  patient 
required  to  regard  the  test-light.  The  right  image  will  be  smaller  than 
the  left,  and  have  a  blue  center  and  a  red  border  if  the  patient  is  hyper- 
opic  or  emmetropic,  and  a  red  center  with  a  blue  border  if  the  patient  is 
myopic.  Suitably  placed  prisms,  which  unite  the  images,  are  the 
measures  of  the  deviation. 

9.  The  Rod  Test. — This  test  was  designed  by  Maddox,  and  depends 
upon  the  propert}-  of  transparent  cA^linders  to  cause  apparent  elonga- 
tion of  an  object  viewed  through  them,  so  that  a  point  of  light  becomes 
a  line  of  light  so  dissimilar  from  the  test-light  that  the  images  are  not 
united.  It  may  be  suitably  employed  by  having  mounted  in  a  cell, 
which  will  fit  in  the  trial-frame,  a  transparent  glass  rod  colored  red,  ^ 
inch  long,  and  about  the  thickness  of  the  ordinary  stirring  rod  used  by 
chemists,  or  a  series  of  glass  rods  placed  one  above  the  other  (Fig.  36) 

The  examination  for  horizontal  deviation  is  thus  described :  ' '  Seat 
the  patient  at  6  meters  from  a  circle  of  light  5  mm.  in  diameter,  and 
place  the  rod  horizontally  before  one  eye.  If  the  line  passes  through 
the  circle  of  light,  there  is  orthophoria 
(equipoise),  as  far  as  the  horizontal  move- 
ments of  the  eyes  are  concerned.  Should 
the  line  lie  to  either  side  of  the  circle  of 
light,  as  in  most  people  it  will,  there  is  either 
latent  convergence  or  latent  divergence;  the 
former,  if  the  line  is  on  the  same  side  as  the 
rod  (homonymous  diplopia) ;  the  latter,  if  on 
the  other  side  (crossed  diplopia)." 

In  order  to  test  the  vertical  deviation, 
the  rod  is  placed  vertically  before  the  eye; 
a  horizontal  Une  of  light  appears,  and  the 

patient  is  asked  if  the  line  passes  directly  through  the  flame  or  if  it 
appears  above  or  below  it.  The  following  rule,  quoted  from  Maddox, 
will  suffice  to  indicate  the  "  hyperphoric  "  eye:  "If  the  circle  of  light  is 
lowest,  there  is  a  tendency  to  upward  deviation  of  the  naked  eye;  if  the 
line  is  lowest,  of  the  eye  before  which  the  rod  is  placed." 

The  measurement  of  the  extent  of  the  deviation  may  be  made  in 
the  ordinary  waj^  by  finding  that  prism,  placed  before  the  naked  eye 
(preferabl}'  with  the  rotary  prism  of  Risley),  which  brings  the  line  and 
flame  together. 

Of  the  various  tests  described,  the  Maddox  rod  is  simple,  and  for  all 


Fig.  36. — Maddox  multiple  rod. 


80     EXTERNAL  EXAMINATION  OF  THE  EYE — FUNCTIONAL  TESTING 

practical  purposes  accurate,  especially  when  it  is  employed  to  estimate 
vertical  deviations.  According  to  Duane,  it  is  apt  to  indicate  an  ex- 
cess of  deviation,  particularly  in  esophoria.  To  oviate  this  fault  P. 
Dolman  sugoests  a  combination  of  the  screen  and  Maddox  rod  test 
(Maddox  rod-screen  test). ^     Hansell  and  Reber  doubt  if  the  prism-test 

a.  b  c 


O        O 


o 


Fig.  37. — Maddox's  rod  test  for  horizontal  deviation.  The  rod  is  before  the  right 
eye.  a,  The  line  passes  throuKh  the  rircle  of  light — orthophoria,  h.  The  line  passes  to 
the  right  of  the  light — ^latent  convergence,  or  esophoria.  c,  The  line  passes  to  the  left 
of  the  light — latent  divergence,  or  exophoria. 

reveals  the  true  state  of  the  muscle  balance.  They  have  found  distinct 
contradictions  between  its  results  and  those  of  the  Maddox  rod  and 
other  tests,  and  this  is  a  matter  of  common  experience.  The  screen 
and  parallax  tests,  if  carefully  and  repeatedly  performed,  give,  as 
Duane  has  demonstrated,  most  trustworthy  infornuition. 

a  d  c 


■e 


o 


o 


Fig.  3s. — Maddox's  rod  test  for  vertical  deviation.  The  rod  is  l)efore  the  right  eye 
a,  The  line  passes  through  the  circle  of  light — orthophoria,  b,  The  line  passt>s  below 
the  light.  The  upper  image  belongs  to  the  left  eye — right  hyperphoria,  c,  The  line 
passes  above  the  light.     The  upper  image  belongs  to  the  right  eye — ^left  hyperphoria. 

Amplitude  Convergence. —  In  oider  to  determine  the  maximum 
of  converKcnce,  an  iustrumtMit  known  as  an  opltthahnodynanioindir 
may  be  employed.  The  best  one  has  been  devised  by  Landolt,-  and 
consists  of  a  metallic  cylinder,  blackened  on  the  outside,  placed  over  a 
candle-flame.  The  cylinder  contains  a  vertical  slit,  0.3  nun.  wide, 
covered  by  f»,roun(l  gla.ss.  The  luminous  vertical  line  thus  productMl  is 
the  object  of  fixation.  Beneath  the  cylintier  is  attached  a  tape-m(>asure 
graduated  on  one  side  iti  centimeters,  and  on  the  other  in  the  cor- 
responding number  ol  inch  r  .iiigles.  The  fixation  object  is  gradually 
approached  in  the  me(han  line  toward  the  patient,  until  that  point 
where  (l()ul)le  vision  occurs  is  reached,  or  the  n(>arest  point  {ptturhini 
proximuni)  of  convergence,  and  the  distance  in  cenliinelers  read  from 

'  Archives  of  Oplitlialinolony,  ''^I'pt.,  I'.H'.t. 

'  Ldtidolt's  Hcfnictioii  juiil  .Vccoiumodatioii  of  the  Myc,  |).  "JS.S. 


THE   FIELD    OF  VISION  81 

one  side  of  the  tape,  and  the  corresponding  maximum  of  convergence 
in  meter  angles  on  the  other. 

The  minimum  of  convergence  may  also  be  ascertained  with  the 
instrument,  but  when  this  is  negative  it  is  determined  by  finding  the 
strongest  abducting  prism — that  is,  base  in  before  one  eye — which  will 
not  cause  diplopia  while  the  patient  is  fixing  a  candle-fiarne  at  6  meters. 
If  the  number  of  the  prism  is  divided  by  7,  the  quotient  will  approxi- 
mately give  in  meter  angles  the  amount  of  deviation  of  each  eye  when 
the  prism  is  placed  before  one.  The  amplitude  of  convergence  is 
equivalent  to  the  difference  between  the  maximum  and  minimum  of 
convergence — that  is,  a  =  p  —  r.  Thus,  if  the  normal  average  of 
maximum  convergence  is  9.5  meter  angles  and  the  average  minimum 
of  convergence  is  —  1  meter  angle,  the  amphtude  of  convergence 
would  be  a  =  9.5  —  (—  1)  =  10.5  meter  angles.  (See  Meter  Angles, 
page  44.) 

The  Field  of  Vision. — When  the  visual  axis  of  one  eye  is  directed 
to  a  stationary  point,  not  only  is  the  object  thus  ''fixed"  or  "fixated" 
visible,  but  also  all  other  objects  contained  within  a  gi\^en  space, 
which  is  large  or  small,  in  proportion  to  the  distance  of  the  fixation 
point  from  the  eye.  This  space  is  the  field  of  vision,  and  the  objects 
within  it  imprint  their  images  upon  the  peripheral  portions  of  the 
retina,  or  those  which  are  independent  of  the  macula  lutea.  In 
contradistinction  to  visual  acuteness  and  refraction,  which  pertain 
to  the  macula  in  the  act  of  direct  vision,  the  function  of  sight  capable  of 
being  performed  by  the  rest  of  the  retina  is  called  indirect  vision. 

The  limits  of  the  visual  field  may  be  roughly  ascertained  in  the 
following  manner:  Place  the  patient  with  his  back  to  the  source  of 
light,  and  have  him  fixate  the  eye  under  examination,  the  other  being 
covered,  upon  the  center  of  the  face  of  the  observer  or  upon  the  eye  ot 
the  observer  which  is  directly  opposite  his  own,  at  a  distance  of  2  feet. 
Then  let  the  surgeon  move  his  hand  in  various  directions  midway 
between  himself  and  the  patient,  on  a  plane  with  his  own  face,  until 
the  limits  of  indirect  vision  are  determined,  controlling  at  the  same 
time  the  extent  and  direction  of  the  movements  by  his  own  field  ot  vision. 

In  place  of  the  hand  other  test  objects  may  be  employed.  The 
author  is  accustomed  to  use  ivory  balls,  10  mm.  in  diameter,  white 
and  colored;  mounted  on  the  ends  of  black  rods  45  cm.  in  length. 
The  technic  of  examination  is  precisely  the  same  as  that  of  the  "hand- 
test."  Duane  recommends  as  a  suitable  test  object  for  this  purpose 
a  white  card  with  a  round  black  spot  1  to  3  mm.  in  diameter  on 
each  side  of  it,  and  for  color  tests  a  small  colored  square  on  each  side 
of  a  gray  card,  the  gray  having  the  same  light  value  as  the  color  which 
it  bears.  These  methods,  confrontation  methods,  to  use  Duane's 
descriptive  term,  furnish  trustworthy  results.  Naturally  in  the 
event  of  the  discover}^  of  any  defect  in  the  visual  fields  they  must  be 
measured  by  the  more  exact  procedures  of  perimetry. 

If  it  is  desired  to  have  a  map  of  the  field  not  larger  than  45°  in  ex- 
tent, let  the  patient  be  placed  25  cm.  from  a  blackboard,  which  may  be 


82     EXTERNAL  EXAMINATION  OF  THE  EYE  —FUNCTIONAL  TESTING 

conveniently  ruled  in  squares,  and  fixate  the  eye  under  observation 
upon  a  small  white  mark.  '1  he  observer  then  moves  the  test-object — 
a  piece  of  white  or  colored  paper  1  cm.  square,  affixed  to  a  black  handle 
— from  the  periphery  toward  fixation,  until  the  object  is  seen.  If 
eight  peripheral  jioiiits  are  marked  and  afterward  joined  by  a  line,  a 
fair  map  of  the  tieldof  vision  will  be  obtained,^  which  may  be  trans- 
cribed upon  a  chart,  like  the  onr-  originally  suggested  by  Joy  Jeffries 
(Fig.  39). 

Bjerrum's  Method. — This  method,  proposed  by  Bjerrum  in  1899, 
consists  essentially  in  the  use  of  white  test-objects  which  subtend  a 
very  small  visual  angle,  the  examination  to  be  made  at  a  distance  of 
2  meters,  while  the  eye  fixates  the  marked  center  of  a  black  screen  2 
meters  in  breadth,  which  can  be  let  down  from  the  ceiling  to  the  floor. 
In  place  of  Bjerrum's  curtain,  Duane's  tangent  plane  serves  an  admir- 
able purpose. 

Bjerrum's  test-objects  are  small,  circular  discs  of  ivory,  fixed  on 
the  ends  of  long,  dull,  black  rods.  They  vary  from  1  to  10  mm.  in 
diameter.  The  examination  may  begin  in  the  ordinary  manner  (at  30 
cm.)  with  the  10  mm.  disc  and  continue  at  2  meters'  distance  with  a 
3-mm.  disc.  In  the  first  instance  the  visual  angle  approximately  is 
2°;  the  normal  boundaries  of  the  field  have  been  recorded  (page  85). 
In  the  second  instance  the  visual  angle  is  approximately  5°;  the  field 
boundaries  are  35°  outward,  30°  inward,  28°  downward,  and  25°  upward. 
At  a  distance  of  2  meters,  the  Wind  spot,  for  example  (see  page  88), 
instead  of  measuring  2.5  cm.,  as  on  an  onlinary  perimeter,  measures 
20  cm.  in  diameter. 

As  ordinarily  employed,  the  Bjerrum  curtain,  or  its  equivalent,  is 
placed  at  0.75  meters  (30  inches)  from  the  eye,  if  it  is  desired  to 
ascertain  the  hmits  of  the  visual  field  within  50°  from  the  center,  and 
at  1.5  meters  (GO  inches)  if  it  is  desired  to  search  for  and  investigate 
central  and  paracentral  scotomas  and  enlargements  of  the  blind  sj)ot.-' 

'  The  value  in  degrees  of  the  squares  on  the  blackboard  may  he  ascertained  by 
the  following  table,  provided  the  ej'e  is  placed  exactly  at  25  cm.  from  the  fixation 
point: 

2.2  cm.  =    5°  in  the  perimeter  semicircle. 

II  1  no         ( I  >  <  < ( 

4.4  cm.  =  10 

6.  i  cm.  =15 

9. 1  cm.  =  20 

11./  cm.  =  2o 

14.4  cm.  =  30'      " 

17.5  cm.  =  35°  " 
21  cm.  =  40°  " 
25  cm.  =  45°  " 
30      cm.  =  50°      " 

36.7  cm.  =  55°      "  "  " 

43.3  cm.  =  60°  " 
-  W.  Ci.  Sym  and  A.  11.  H.  Sinclair  liavc  (Icsrril)C(l  the  ii»'C('.s.snry  appanitus  for 
Mjcrrum's  test  for  ecotoma.s  in  the  Held  of  vifiion  (Ophthalmic  Hcvicw,  llXXi,  WA. 
XXV,  |).  141);  and  T.  H.  Holloway  has  dcsiniifd  a  conveniently  mounted  .set  tif 
Hjerrum'.s  tests,  white  and  colored.  (Transactions  of  the  American  Ophlhal- 
moionical  Society,    I'.til.   \ol.    \!I  p.  •MIC).) 


THE    FIELD    OF   VISION 


83 


Because  the  Bjerrum  curtain  and  its  equivalents  are  somewhat 
cumbersome,  and  in  many  circumstances  are  with  difficulty  evenly 
illuminated,  various  forms  of  campimeters  have  been  designed,  among 
which  the  hand  campimeter  of  L.  C.  Peter^  is  a  noteworthy  and  satis- 
factory instrument.  It,  as  Peter  properh-  maintains,  is  adapted  to 
studies  within  30°  of  the  fixation  point,  and  a  reasonable  degree  of 
accuracy  can  be  obtained  in  peripheral  delimitations  of  the  field  up 
to  40°. 

From  the  preceding  descriptions  it  is  evident  that  beyond  45°  the 
campimeter  method  ceases  to  be  accurate,  because  on  a  flat  surface 
the  object  is  too  far  away  from  the  eye;  rays  perpendicular  to  the 
visual  line  coming  from  a  peripheral  object  would  be  parallel  to  the 
blackboard,and  could  not  arise  from  it,  or  any  object  passed  across  its 
surface. 


^^ 

— 

— 

— 

■^ 

\ 

„» 

^ 

\ 

V 

t' 

-"' 

^,- 

,_. 

■-, 

\ 

\ 

, 

t 

\ 

s 

\ 

\ 

f  .' 

+ 

/ 

\ 

) 

\ 

% 

/' 

* 

J 

t 

> 

V 

*, 

»» 

■'— 

-. 

' 

/ 

\ 

«_l 

— 

" 

^# 

J 

\f 

s 

s 

J 

s^ 

— 

^ 

J 

White 

Blue--  — 
Red 

Fig.  39. — Limits^of  the  normal  field  for  white,  blue,  and  red,  transcribed  upon  a  black- 
board (after  Norris). 


Hence,  the  investigation  of  the  periphery  of  the  retina  requires 
the  use  of  an  instrument  known  as  a  perimeter.  This  consists  essenti- 
ally of  an  arc  marked  in  degrees,  which  rotates  around  a  central  pivot, 
that  at  the  same  time  may  be  the  fixing-point  of  the  patient's  eye, 
which  is  placed  30  cm.  distant  (the  center  of  curvature  of  the  perimeter 
arc),  or  the  eye  may  be  directed  upon  a  porcelain  button  on  a  bar, 
placed  15°  from  the  center,  to  the  left,  if  the  right  eye  is  to  be  examined; 
vice  versa,  if  the  left  is  under  observation.  The  test-object,  5  to  10  mm. 
in  diameter,  affixed  upon  a  carrier,  is  moved  from  without  inward,  and 
the  point  noted  on  each  meridian  where  it  is  recognized.  The  result 
is  transcribed  upon  a  chart,  prepared  by  having  ruled  upon  it  radial 
lines  to  correspond  to  the  various  positions  of  the  arc,  and  concentric 
circles  to  note  the  degrees. 

^lany  ingenious  instruments  have  been  devised,  especially  such  as 
are  self -registering,  among  which  may  be  mentioned  those  of  McHardy, 
1  Principles  and  Practice  of  Perimetry,  1916. 


84     EXTERNAL  EXAMINATION  OF  THE  EYE — FINCTIONAL  TESTING 

Stevens,  Skeel,  and  Priestley  Smith.  "Electric  light  perimeters" 
or  "self-lit"  perimeters  have  been  designed,  for  example  by  C.  H.  Wil- 
liams and  William  Sweet,  and  Ferree  has  constructed  a  perimeter  the  elec- 
trical illumination  of  which  is  so  arranged  that  it  remains  evenly  con- 
stant no  matter  in  what  position  the  arc  is  rotated  around  its  central 
pivot.  Elliot,  "di.s.satisfied  with  the  limitations  imposed  bj'  the  flat 
screen  employs  a  perimeter  of  1  meter  radius,  which  is  adapted  to 
work  either  in  the  dark  or  by  reflected  light." 


OOOA 


Fig.  40. — Perimeter.  The  i'.\amiiiatioii  may  be  made  witli  the  carrier  which  moves 
along  the  semicircle,  or  the  te.st-ol)ject.s  may  l>e  carried  along  this  by  means  of  dark 
disks  attached  to  a  long  handle,  each  disk  containing  in  its  center  tiie  test-object.  The 
patient's  chin  is  placed  in  the  curveil  chin-rest;  tin-  notched  end  of  the  upright  bar  is 
brought  in  contact  with  the  face,  directlj'  ijeneath  the  eye  to  be  examined,  which  atten- 
tively fixes  the  center  of  tlie  semicircle.  The  other  eye  should  be  covered,  preferably 
with  a  neatly  adjusted  bandage.  The  record  chart  is  inserteii  at  the  back  of  the  instru- 
ment, and,  by  means  of  an  ivory  vernier,  the  examiner  is  enabled  ot  mark  exactly  with 
a  pencil  the  point  on  the  chart  corresijonding  to  the  position  on  tlie  semicircle,  at  which 
the  patient  sees  the  test-object.  The  various  marks  ar»>  tlien  joined  l)y  a  continuous 
line,  and  a  map  of  tlie  field  is  obtained  (see  Fig.  41). 

Self-registering  perimdcis  and  a  sliding  (tbjcct  holder  do  not  achieve 
results  which  arc  as  s;itisfaclory  as  those  obtained  with  test  objects 
attached  to  a  slender  black  rod  or  wire  which  is  movetl  by  hand  along 
the  arc  of  the  perimeter.     The  hand  peiiiiieter  of  Schweigger  for  bed- 


THE    FIELD    OF   VISION 


85 


side  examinations  and  the  more  elaborate  one  of  Wildbrand,  which  can 
be  adjusted  while  the  patient  lies  upon  his  back,  are  useful  instruments. 

The  physiologic  limits  of  the  field  for  a  white  test-object  10  mm. 
in  width,  the  eye  being  30  cm.  from  the  fixation  point  are:  outward, 
90°;  outward  and  upward,  70°;  upward,  50°;  upward  and  inward,  55°; 
inward,  60°;  inward  and  downward,  55°;  downward,  72°;  downward 
and  outward,  85°.^ 

These  measurements,  which  represent  the  relative  visual  field  ,vary 
within  normal  limits,  and,  transcribed  upon  a  chart,  produce  the  fol- 
lowing figure    (Fig.    41). 

From  this  it  is  evident  that 
the  field  of  vision  is  not  circular, 
being  greatest  in  extent  outward 
and  below,  and  most  restricted 
inward  and  above.  This  restric- 
tion is  partly  due  to  the  presence 
of  the  edge  of  the  orbit  and  the 
nose,  and  partly,  as  Landolt  has 
pointed  out,  because  the  outer 
part  of  the  retina  is  less  used 
than  the  inner,  and  its  functions, 
therefore,  are  less  developed. 
Hence,  as  each  portion  of  the 
field  corresponds  to  the  opposite 
portion  of  the  retina,  the  inner 
part  is  smaller  than  the  outer. 

It  must  be  remembered,  how- 
ever, that  the  size  of  the  field  of  vision  varies  with  the  size  of  the  visual 
angle  subtended  by  the  test-object  with  which  the  examination  is  con- 
ducted, and  for  the  sake  of  accuracy  the  size  of  the  object  should  be 
given  as  well  as  its  distance  from  the  patient's  eye.  Moreover,  the 
visual  field  should  not  be  mapped  with  test-objects  of  one  size  onl3^ 
As  Ronne,  quoted  by  Traquair,  says:  "An  examination  of  the  field  of 
vision  in  which  only  one  object  is  used  is  in  itself  just  as  inadequate  as 
an  examination  of  visual  acuteness  with  a  test  card  which  has  letters  of 
only  one  size."^ 

^  Baas  finds  the  average  result  of  ten  observers  as  follows:  Outward,  99°;  up- 
ward, 65°;  inward,  63°;  downward,  76°.  Figures  indicating  a  minimal  field,  or 
smallest  physiologic  field,  have  been  recorded,  varying  from  90°  (Foerster)  to  50° 
(Treitel)  outward;  55°  to  21°  upward;  60°  to  40°  inward;  70°  to  40°  downward. 
The  smaller  of  these  limits  cannot  be  regarded  as  physiologic,  and  the  greater  is 
about  equal  to  the  average  working  field.  Wolffberg  insists  that  a  field  obtained 
under  ordinary  daylight  illumination  should  be  controlled  by  one  obtained  with 
reduced  illumination. 

^  H.  M.  Traquair  (Ophthalmic  Review,  1914,  vol.  xxxiii,  p.  65)  gives  an  ex- 
cellent account  of  the  quantitative  method  in  perimetry.  Clifford  B.  Walker,  in 
his  examinations  of  patients  with  intracranial  lesions  in  Harvey  Cushing's  service, 
found  it  necessary  to  investigate  the  field  for  test-objects  varying  in  visual  angle 
from  1  or  2  minutes  to  about  8°,  and  has  designed  a  series  of  nine  circular  rimless 
colored  and  white  disks  supported  on  wire  handles  which  cover  the  required  range, 


Fig.  41. — Diagram  of  the  field  of  vision 
for  white  (1  cm.  square  test-object),  tran- 
scribed upon  a  perimeter  chart. 


80     EXTERNAL  EXAMINATION  OF  THE  EYE — FUNCTIONAL  TESTING 

Binocular  Field  of  Vision. — The  field  of  vision  for  each  eye  having 
been  defined,  it  remains  to  point  out  that  the  field  of  vision  which 
pertains  to  the  two  eyes,  or  that  portion  in  which  binocular  vision  is 
possible,  constitutes  only  the  area  where  the  central  and  inner  parts 
overlap.  This  is  evident  from  the  diagram.  The  continuous  line  L 
bounds  the  field  of  vision  of  the  left  eye,  and  the  dotted  line  R  the  visual 
field  of  the  right  eye.  The  central  white  area  corresponds  to  the  por- 
tion common  to  both  eyes,  or  to  that  area  in  which  all  objects  are  seen 
at  the  same  time  with  both  eyes;  the  shaded  areas  correspond  to  the 
portions  in  which  binocular  vision  is  wanting.  In  the  middle  of  the 
white  area  lies  the  fixation  point/,  and  on  each  side  of  it  the  bhnd-spots 
of  the  right  and  left  e\'e,  ;•  and  /. 


Fig.  42. — Binocular  field  of  vision  (Moser). 

Having  thus  determined  the  limits  and  continuity  of  the  visual  field, 
the  functions  of  the  peripheral  parts  of  the  retina  in  regard  to  percep- 
tion of  colors,  acuteness  of  vision,  and  appreciation  of  light  should  be 
investigated. 

The  color-field  is  mapped  in  the  manner  described  in  connection 
with  the  general  visual  field,  the  squares  of  white  being  replaced  by 
pieces  of  colored  paper. 

The  order  in  which  the  colors  are  recognized  from  without  inward  is: 
(1)  Blue;  (2)  yellow;  (3)  orange;  (4)  red;  (5)  green;  (ii)  violet.  In 
practical  work,  blue,  red,  and  green  are  the  colors  employed,  red  and 
green  being  the  color-sense  most  usually  affected  in  pathologic  cases. 
Non-saturated  colors  are  not  correctly  recognized  when  the  test-object 
is  first  seen.     Thus,  yellow  at  first  appears  white;  orange,  yellow;  red, 

taking  the  "normal"  or  5-mm.  disk  ixs  the  unit.  In  tlii.s  series  the  smallest  disk 
is  0.15  mm.  and  the  largest  4  cm.  in  diameter.  His  special  perimeter  has  a  radius 
of  28.0  cm.  and  a  large  working  surface  (10°  l)y  \\\Q°  in  extent.  Col.  Klliot  hepre- 
cates  the  uise  of  10  or  even  5  mm.  disks  as  being  umiece.s.s;irily  large,  .^ccordin^; 
to  him  with  a  dayliglit  perimeter  of  \VM  mm.  radius  the  test  object  used  need  be  no 
larger  than  between  'IX)  and  2.S  mm.  in  diameter,  becau.se  "a  full  norm.nl  field,  for 
a  white  ol)ject  can  be  obtainecl  from  a  healthy  eye,  if  we  use  that  object  of  such 
a  size  that  its  diameter  sul)tends  an  angle  of  h.ulf  a  degree  at  the  nod.al  |>oint." 
Naturally,  if  the  dimensions  of  the  oljject  used  is  reduced,  the  si/e  of  the  field  will 
be  decrea.sed. 

To  make  record  of  the  size  of  the  test  object  and  the  distiince  of  the  eye  from 
the  perimeter  A.  H.  H.  Sinclair  suggests  that  the  size  sludl  be  the  mimerator  of:* 
fraction,  the  denominator  of  which  shall  be  the  distance,  both  i)eing  exjire.ssed  in 
mm.,  for  e\!imi)le:  visual  fields  olitained  by  test  ''jooo-  '''jooo.  '?Soo- 


THE    FIELD   OF  VISION 


87 


brown;  green,  white,  gray,  or  gray-blue;  and  violet,  blue.  The  physio- 
logic limits  of  the  color-fields,  which,  like  those  of  the  general  field,  are 
subject  to  variations,  when  estimated  with  a  1  cm.  square  test-object, 
the  eye  being  30  cm.  from  the  fixing  point,  correspond  closely  to  the 
following: 

Blue  Red  Green 

Outward 80  65  50 

Outward  and  upward 60  45  40 

Upward 40  33  27 

Upward  and  inward 45  30  25 

Inward 45  30  25 

Inward  and  bownward 50  35  27 

Downward 58  45  30 

Downward  and  outward 75  55  45 


These,  when  transcribed  upon  a  chart,  are  represented  in  Fig.  43. 

The  numbers  represent  the  usual  limits  at  which  the  color-test  1  cm. 
square  is  recognized  as  such.  They  do  not  indicate  its  greatest 
intensity,  which  is  perceived  only  at  the  fixation  point.  In  order  to 
avoid  discrepancies,  the  character  of  the  light,  the  nature  and  satura- 
tion of  the  color,  and  the  size  of  the  test-object  should  be  stated 
in  describing  examinations.  Always  the  visual  field  for  colors  as  well 
as  for  white  should  be  investigated  with  test-objects  of  various  sizes 
(see  also  page  85). 

It  should  be  remembered  that  --      ^sfi- 

the  boundaries  of  the  color-field 
which  have  been  described  result 
from  examination  with  test- 
objects  not  greater  than  1  cm. 
square.  With  larger  areas  of  /«/ 
color  it  will  be  found  that  the 
color-fields  differ  in  extent  very 
little  from  the  fields  for  white. 

According  to  Wolffberg,  the 
color-limits  contract  concentric- 
ally as  the  illumination  is  re- 
duced, but  if  the  photochemical 
and  neuroptic  apparatus  is  nor- 
mal, there  will  be  no  change  in 

the  normal  sequence  of  the  color-  Fig.  43.-Diagram  of  the  field  of  vision  for 

limits.      Blue  should  be  employed  blue,  red,  and  green.     The  outer  continuous 

in  investigating   defects  in   the  !!^V"'^r°''*''' .*''^^'""*  f  ^^'^  ^'?™;^?i'^=  ^^'^ 

,      ,       ,  .      .  .      broken  lines,  the  limits  of  the  color-fields. 

photochemical   apparatus,  as  it 

is  the   color  first  to   disappear  in  reduced  illumination;  red  suffers 

promptly  in  reduced  excitability  of  the  neuroptic  apparatus. 

Important  as  the  study  of  the  color  fields  is  their  accurate  deter- 
mination is  fraught  with  many  difficulties  largely  owing  to  the  failure 
in  the  standardization  of  color-tests.  For  this  reason  it  is  often  the 
ease  that  visual  fields  plotted  carefully  with  white  test-objects  of  vary 


88     EXTERNAL  EXAMINATION  OF  THE  EYE — FUNCTIONAL  TESTING 

ing  sizes   (see  page  85)   yield  more  accurate  information  than  tliat 
derived  from  the  color-fields  (see  page  86). 

The  acuteness  of  the  vision  of  the  peripheral  parts  of  the  retina  may  be 
tested  with  small  squares  of  black  paper  (6,  5.3  and  2  mm.  black  quad- 
rants on  a  white  ground),  separated  from  one  another  by  their  own 
width,  by  noting  the  point  in  each  meridian  where  they  are  recognized 
as  separate  objects:  or  with  gray  patches  of  different  intensity  on  a 
white  ground  (Ward  Holden). 

The  light-sense  of  the  periphery  of  the  retina  may  l>e  tested  con- 
veniently with  Ward  Holden's  tests.  One  card  has  a  1  mm.  black 
point  on  one  side  and  a  15  mm.  quadrant  of  light  gray,  having  four- 
fifths  of  the  intensity  of  white,  on  the  other.  With  a  perimeter  of  30 
cm.  radius  the  black  point  and  gray  patch  are  each  seen  by  a  normal 
eye  outward,  45°;  upward,  30°;  inward,  35°;  downward,  35°.  The 
second  card  has  a  3  mm.  black  point  on  one  side  and  a  darker  gray 
patch,  having  three-fifths  of  the  intensity  of  white,  on  the  other. 
Each  is  seen  on  the  perimeter  arc  outward,  70°;  upward,  45°;  inwaril. 
55°;  downward,  55°.  Card  2  will  reveal  slight  disturbances  of  light- 
sense  near  the  periphery  and  card  1  in  the  intermediate  and  central 
zones. 

The  perception  of  light,  according  to  the  experiments  of  Landolt.  is 
the  most  constant  function  of  the  healthy  retina,  and  remains  nearly 
the  same  throughout  its  surface,  while  the  color-  and  form-sense  rapidly 
lessen  toward  the  periphery.  For  practical  purposes,  a  candle-flame 
or  small  electric  bulb  passed  along  the  arm  of  the  perimeter  may  be 
used  as  a  test-object;  and,  if  vision  is  very  defective,  a  second  candle 
or  bulb  is  made  the  point  of  fixation.  This  test  does  not  demonstrate 
the  light  perceiving  power  of  the  retina  unless  the  patient  is  able  not  only 
to  tell  when  it  is  light  and  when  it  is  dark,  but  to  indicate  accurately 
where  the  light  is  and  from  what  direction  it  is  coming  (see  also  jiage  412). 
Progressive  diminution  of  light-sense  from  center  to  periphery  will 
be  found  if  test-objects  of  varying  luminous  intensitj',  with  the  illu- 
mination of  ordinary  davlight,  are  employed. 

The  adaptation  of  the  retina  may  be  estimated  according  to  Wil- 
brantl's  method  bv  investigating  the  visual  field  in  a  dark  room  with 
test-object  and  fixation  point  streaked  with  luminous  paint.  The 
examination  is  made  as  soon  as  the  patient  enters  the  dark  room  and 
again  in  ten  minutes.  This  interval  is  sufficient  to  enable  the  normal 
eye  to  adapt  itself  so  that  the  extent  of  the  visual  field  corii'sponds  to 
that  of  a  white  object  in  dilTuse  daylight.  Delayed  adaptation  is  a 
j)h('ii()iiicii()ii  found  in  nian\'  paliiologic  conditions  (see  also  page  alio). 

Abnormalities  of  Visual  Field  and  Scotomas.— The  most  frequent 
departures  from  those  limits  of  the  visual  field  assumed  to  be  normal 
are  geneial  or  concentric  contiact ion;  contraction  limittnl  (^specially  to 
one  or  the  other  sid<';  peripheral  defects  in  tiie  form  of  re-entering 
angles;  absence  of  one  .segment  or  (Hiadiant  :  and  al>seiice  of  the 
(Uitire  right  or  left  half  of  the  field. 

In  addition  to  these  defects,  s(>iircli  should  be  uiade  for  dark  .areas 


I 


THE    FIELD    OF  VISION  89 

within  the  Kmits  of  the  visual  field,  or  scotomas.  These  are  distin- 
guished as  positive  when  the\^  are  perceived  by  the  patient  in  his  visual 
field,  and  negative  when  within  the  confines  of  a  portion  of  the  visual 
field  the  image  of  an  external  object  is  usually  not  perceived,  and  the 
affected  area  is  generally  not  discovered  until  the  field  is  examined. 
Negative  scotomas,  however,  may  also  be  positive  in  the  sense  that 
the  affected  areas  of  the  retina  which  are  insensitive  to  luminous 
impression  can  be  recognized  as  dark  areas  and  be  projected  exteriorly 
(Fuchs).  Negative  scotomas  are  further  divided  into  absolute  and 
relative.  "Within  an  absolute  scotoma  all  perception  of  fight  is  wanting, 
while  within  the  confines  of  a  relative  scotoma  the  perception  of  light 
is  mereh'  diminished.  The  latter  are  color  scotomas,  usually  for  red 
and  green.  Scotomas  are  further  subdivided,  according  to  their 
situation  and  form,  into  central,  paracentral,  ring,  peripapillary,  and 
peripheral.^  A  normal  eye  will  develop  a  relative  central  scotoma 
in  a  darkened  room,  and  if  the  darkness  is  increased  the  scotoma 
becomes  absolute  (Hess). 

In  every  normal  eye  there  is  a  physiologic  scotoma,  corresponding 
to  the  position  of  the  optic  nerve  entrance,  which  usually  maj^  be  found 
15°  to  the  outer  side  of  and  3°  below  the  point  of  fixation;  the  interval, 
according  to  Landolt,  being  greater  in  hyperopic  than  in  myopic  eyes. 
This  is  known  as  Mariotte's  blind-spot.  It  is  surrounded  by  a  narrow 
zone  of  relative  amblyopia  for  white  about  1°  in  width.  According 
to  Hansell,  the  average  distance  of  the  center  of  the  blind-spot  from 
fixation  point  is  almost  identical  in  emmetropia  and  hyperopia,  but  in 
myopia  is  about  5  mm.  greater.  Should  the  horizontal  diameter  of  the 
bhnd-spot  for  motion  exceed  6°,  according  to  Van  der  Hoeve,  it  is 
larger  than  normal,  and  may  indicate  the  presence  of  beginning 
pathologic  change. 

For  the  delimitoiion  of  scotomas,  small  test-objects,  white  or  colored, 
I  cm.  square,  may  be  employed,  which  are  moved  in  different  directions 
from  the  point  which  the  eye  under  observation  attentively  fixes,  and 
the  spot  marked  where  the  object  begins  to  disappear  or  change  its 
color.  The  arm  of  the  perimeter  is  usually  marked  near  the  center  in 
,  haff-degrees  for  this  purpose.  Scotoiyias  including  the  blind  spot  how- 
I  ever,  are  best  mapped  out  on  Bjerrum's  curtain  or  its  equivalent 
I  (Duane's  tangent  plane)  or  with  the  aid  of  a  campimeter,  for  example 
Peter's  which  is  well  adapted  for  the  purpose.  Employing  the 
Bjerrum'  method  the  patient  should  be  1.5  to  2 meters  from  the  curtain 
and  the  test  objects  2  to  5  mm.  in  diameter  (page  82). 

Duane  recommends  the  complimentary  color  test  (extinction  test) 
applied  with  the  tangent  curtain  for  the  examination  of  scotomas  or 
the  blind  spots  at  a  distance  of  1.5  meters.  The  method  is  as  follows: 
Should,  for  example,  the  left  eye  be  under  examination  it  remains 
^  For  a  scotoma  which  lies  between  the  fixation  point  and  the  blind-spot,  such 
as  occurs  in  toxic  ambj-lopia  (see  page  538),  Traquair  proposes  the  name  centrocecal 
scotoma,  and  for  other  defects  of  the  central  part  of  the  field  the  terms  supracentral. 
infracentral,  nasocenlral,  temporocentral,  and  for  defects  adjacent  to  the  papilla, 
supracecal,  temporocecal,  etc. 


90     EXTERNAL  EXAMINATION  OF  THE  EYE — FUNCTIONAL  TESTING 

uncovered,  while  the  right  eye,  covered  witli  a  deep  amber  or  a  ruby 
glass  fixates  the  central  spot  of  the  curtain.  Next  a  dark  blue  disk 
on  a  carrier  is  passed  in  various  directions  along  the  curtain.  This 
disk  is  invisible  bj'  the  right  eye,  because  it  is  extinguished  by  the 
colored  glass,  but  is  visible  to  the  left  eye  as  a  lighter  blue  until  it 
enters  the  scotoma  when  it  disappears  if  the  scotoma  is  absolute  or 
becomes  dim  and  dark. 

Special  instruments  for  detecting  and  measuring  scotomas — 
scotometers — have  been  designed  by  Priestley  Smith,  P.  C.  Bardsley 
and  R.  H.  Elliot  who  has  combined  the  advantages  of  Priestley 
Smith's  instrument  with  those  of  Bjerrum's  curtain  by  working  at  a 
distance  of  1  meter.  Haitzemploys  a  stereoscope  with  diagrams  which 
gives  binocular  fixation.  The  card  before  the  eye  to  be  tested  is 
covered  with  small  squares  with  which  the  defect  is  detected  and 
mapped;  each  side  of  a  square  subtends  an  angle  of  1  degree  at  the 
distance  at  which  the  card  is  used.  Haitz's  stereoscopic  chords  and  the 
complimentary  color  test  are  especially  valual^le  in  the  examination  of 
patients  whose  defective  central  vision  does  not  permit  accurate  fixa- 
tion of  the  central  spot  on  the  curtain  or  on  the  campimeter.  BisseU's 
blind  spot  slate  to  be  used  with  a  wide-angled  stereoscope  and  Lloyd's 
stereo-campimcter  are  admirably  adapted  for  the  study  of  Mariotte's 
blind  spot  and  its  anomalies;  the  stereo-campimeter  is  most  valual)le 
in  the  investigation  of  unilateral  central  scotomas  and  defects  in  the 
central  retinal  area. 

Tension. — This  term  indicates  the  resistance  of  the  ocular  tunics, 
and  is  clinically  demonstrable  by  palpating  the  globe  with  the  finger- 
tips. The  middle  and  ring-fingers  arc  placed  upon  the  brow  of  the 
patient,  the  tips  of  the  index-fingers  upon  the  ej'eball,  and  gentle  to- 
and-fro  pressure  made,  the  eyes  being  directed  downward.  This  pres- 
sure must  be  made  in  such  a  manner  as  not  to  push  the  ball  into  the 
orbit;  otherwise  no  information  of  its  true  resistance  is  ol^tained.  The 
tension  of  one  eye  must  always  be  compared  with  that  of  its  fellow, 
and,  in  any  doubtful  case,  the  results  may  be  contrasted  with  those 
obtained  by  examining  an  eye  known  to  be  normal  in  another  jiatifMit 
of  similar  age. 

Normal  tension  is  often  expresi^ed  l)y  the  sign  Tn,  and  the  depart- 
ures from  it  formerly  were  indicated  by  the  symbols  -^  '!,  +  1.  +  2, 
-|-3,  and  —  ?,  —  1,  —  2,  —  3;  the  plus  signs  referred  to  increased,  and 
the  minus  signs  to  decreased,  resistance.  In  physiologic  experiments, 
various  kinds  of  apparatus,  const ructeil  upon  tiie  principle  of  the  man- 
ometei',  are  employed,  and  for  clinical  purposes  instiuments  known  i\s 
tonometers  have  been  devised.  The  most  useful  of  these  is  the  one 
designed  by  Schiotz.  A  modification  of  this  tonometer  luis  been  con- 
structed by  (Iradle,  and  W.  McLean  has  designed  a  iliicel  r(>adiiiii  lo- 
nometer  with  constant  weight  factor. 

The  principle  of  the  eye  tonometer  is  (luis  defined  by  Priestley 
Smith:  The  instrunuMit  m(>asures  tlie  impressibility  of  the  ey(>ball,  and 
from  the  degree  of  impressibilit>-  we  infer  the  intra-ocular  pressure. 


TENSION 


91 


The  Schiotx  instrument,  is  now  in  common  use,  and  its  construction 
may  be  readily  understood  from  the  accompanying  diagram  (Fig.  44). 

The  patient  should  lie  upon  a  table  or  reclining  chair,  with  the  head  thrown 
back,  and  be  requested  to  look  directly  upward.  The  eyeball  is  rendered  insensi- 
tive with  holocain  (2  per  cent,  solution,  three  instillations  at  intervals  of  three 
minutes),  and  the  lids  are  separated  without  making  pressure  on  the  globe.  Next, 
the  surgeon,  holding  the  instrument  (with  the  5.5  gm.  weight  in  place)  by  the  two 
arms  attached  to  the  cuff,  which  slips  up  and  down  the 
hollow  cylinder,  brings  its  foot-piece  exactly  at  rest  on 
the  cornea,  the  cuff  being  slid  down  so  as  to  be  about 
the  middle  of  the  cylinder.  The  instrument  should 
stand  freely,  resting  exactly  on  the  center  of  the  cornea. 
The  deflection  of  the  needle  is  recorded,  and  from  a 
diagram  which  accompanies  the  instrument  it  may  be 
seen  with  how  many  miUimeters  of  mercury  the  deflec- 
tion of  the  needle  corresponds;  thus,  should  the  needle, 
with  the  5.5  gm.  weight  in  place,  register  3,  this  cor- 
responds to  25  mm.  of  mercury.  Schiotz  advises  that 
three  measurements  shall  be  made  and  the  average 
of  the  readings  recorded.  Some  surgeons  prefer  a 
single  reading  taken  with  great  care,  but,  as  Priestley 
Smith  insists,  it  is  not  safe  to  rely  on  a  single  reading ; 
it  should  be  confirmed  by  at  least  t\Vo  additional  read- 
ings. There  are  four  weights,  respectively  5.5,  7.5,  10, 
and  15  gm.  If  the  needle  is  not  deflected  beyond  1,  the 
measurement  should  be  repeated  with  a  greater  weight. 
According  to  Schiotz,  deflections  between  2  and  4  mm. 
yield  the  most  accurate  results.  The  foot-piece  of  the 
instrument  should  be  cleansed  in  a  boric  acid  solution. 

The  normal  pressure  varies  from  16  to  28 
mm.  of  Hg.,  that  is,  16  is  the  low  and  28  the 
high  physiologic  limit,  although  an  eye  with 
a  tension  above  25  mm.,  25.5  to  28,  should 
be  regarded  with  suspicion,  should  be  kept 
under  observation  and  should,  especially  if  the 
anterior  chamber  suggests  shallowness,  receive 
at  night  an  instillation  of  a  drop  of  3^^  per  cent,  solution  of  pilo- 
carpin.  According  to  Schiotz  normal  tension  varies  between  15.5 
and  25;  according  to  Marple,  between  15  and  25;  according  to 
Stock,  between  12  and  26,  and  according  to  Heilbrun,  between  12 
and  27.  Neither  the  state  of  the  refraction  nor  the  age  has  an 
appreciable  effect  on  the  ocular  tension,  nor  is  it  influenced  by 
mydriatics,  except  that  cocain  slightly  diminishes  the  tension  of 
the  normal  eye  (Heilbrun).  According  to  Heilbrun,  eserin  and 
pilocarpin  usually  lower  slightly  the  tension  of  the  normal  eye,  an 
observation  which  was  not  confirmed  by  Marple's  results.  In  this 
respect  the  author's  observations  agree  with  those,  of  Heilbrun.  Al- 
though records  in  the  form  of  mm.  Hg.,  as  stated  above,  are  usually 
made,  as  Priestley  Smith  points  out,  the  reading  and  not  the  supposed 
equivalent  in  mm.  Hg.  should  be  stated  (see  also  page  397).  To 
estimate  the  ocular  tension  by  means  of  the  finger  test  is  not  a  safe  nor 


Fig. 


44. — Schiotz    tonom- 
eter. 


92     EXTERNAL  EXAMINATION  OF  THE  EYE — FUNCTIONAL  TESTING 

an  accurate  procedure,  and  in  all  circumstances  where  this  is  an  im- 
portant observation  the  tonometer  should  be  used.  Tonometric 
measurements  are  required  not  only  if  glaucoma  is  present  or  sus- 
pected, but  for  example  in  cases  of  iridocyclitis,  uveitis,  keratitis, 
especially  interstitial  keratitis,  detachment  of  the  retina,  retinal 
angiosclerosis,  retinal  hemorrhages  and  choked  disk. 

Proptosis,  exophthalmos,  or  protrusion  of  the  eye.  may  be 
caused  by  orbital  diseases  and  tumors,  sinusitis,  tenotomy  and  paraly- 
sis of  the  ocular  muscles.  Graves'  disease,  and  sometimes  by  chronic 
nephritis  (L.  Barker),  and  by  intracranial  neoplasms,  especially  if 
situated  in  the  middle  fossa  of  the  skull;  while  enlargement  of  the  ball 
is  the  result  of  various  conditions  residing  within  the  globe — myopia, 
bnphthalmos,  intra-ocular  tumor,  and  staphyloma.  If  the  cause  is 
unilateral,  the  resulting  condition  is  asymmetric,  and  the  two  ej'es 
may  be  compared  by  observing  the  relative  positions  of  the  apices  of 
the  corneas  with  each  other  and  with  the  line  of  the  brows.  For 
measuring  the  degree  of  exophthalmos  Edward  Jackson  has  devised  a 
simple  scale  or  proptometer.  A  useful  and  accurate  instrument  for 
this  purpose  is  the  exophthalmometer  of  Hertel.  A  more  elaborate 
instrument  is  the  one  designed  by  Lohmann.  A  slight  protrusion  of 
the  eyeball  takes  place  when  the  palpebral  opening  is  voluntarily 
decidedly  widened  (see  also  page  651). 

The  eyeball  is  apparently  sunken  (enophthalmos)  in  some  cases  of 
ptosis,  in  wasting  of  the  orbital  fat,  in  orbital  injury,  and  is  diminished 
in  size  in  high  grades  of  hyperopia  and  congenital  failures  of  develop- 
ment. As  Nettleship  pointed  out,  the  amount  of  exposed  sclera  may 
help  to  decide  the  apparent  protrusion  or  recession  of  the  eyel)all  (see 
also  page  651). 

Position  of  the  Eyes. — Instead  of  presenting  parallel  visual  axes, 
one  eye  may  be  deviated  inward,  outward,  downard,  or  upward,  con- 
stituting one  of  the  various  types  of  strabismus  (s(>e  pagi>  576),  a  con- 
dition which  may  or  may  not  be  associated  with  diplopia  (see  pajie  581). 

Counterfeited  Blindness. — The  methods  for  detecting  malinger- 
ing niiglit  be  included  with  functional  testing  of  the  eye.  They  are 
described  in  Chapter  X\TI,  p.  557,  and  for  convenience  are  allowed  to 
remain  there 


CHAPTER  III 

REFLECTION,   THE   OPHTHALMOSCOPE  AND   ITS   THEORY. 
OPHTHALMOSCOPY  AND  SKIASCOPY 

Reflection. — When  light  falls  upon  a  polished  surface  a  portion  of 
it  is  reflected.  The  angle  of  reflection  is  alwaj^s  equal  to  the  angle  of 
incidence.  A  pohshed  surface,  capable  of  reflecting  light,  is  called  a 
mirror.  Mirrors  are  plane,  concave, 
or  convex. 

A  plane  mirror  reflects  the  rays 
falHng  upon  it,  so  that  they  seem  to 
come  from  a  point  as  far  back  of  the 
mirror  as  the  object  Hes  in  front  of 
it.  It  does  not  render  the  raj^s  either 
convergent  or  divergent,  nor  does 
it  lessen  their  convergence  of  diver- 

-r>  11    1    u    r  a  Fig.  45. — Reflection  from  a  plane  mirror. 

gence.  Kays  parallel  beiore  reflec- 
tion are  parallel  after  reflection.  Rays  convergent  of  divergent  be- 
fore reflection  maintain  the  same  relation  after  reflection.  In  the 
figure,  ra3'S  from  theobject  0-5,  falling  upon  the  mirror,  .V,  are  reflected 
so  that  they  enter  the  observer's  eye,  and  seem  to  him  to  come  from 
O'-B',  situated  as  far  back  of  the  mirror  as  0-B  is  in  front  of  it.     The 


Fig.  46. — Reflection  from  a  concave  mirror. 

image  is  not  inverted.  The  rays  have  a  divergence  from  a  point  whose 
distance  is  equal  to  the  sum  of  the  distance  from  the  light  to  the  mirror, 
and  of  the  distance  from  the  mirror  to  the  eye  (compare  Skiascopy). 
A  concave  mirror  converges  parallel  rays  of  light  to  its  principal 
focus,  and  forms  a  real,  inverted  image  in  front  of  the  mirror. 

93 


94  OPHTHALMOSCOPY    AND    SKIASCOPY 

The  principal  focus  of  a  concave  mirror  is  equal  to  one-half  the 
length  of  its  radius  of  curvature,  F  =  ^• 

The  conjugate  focal  distance  for  any  point  greater  than  the  princi- 
pal focus  may  be  found  by  the  following  formula:  /'  represents  the 
distance  from  which  the  rays  diverge  (the  lamp  or  candle);/"  is  the 
distance  of  the  conjugate  focus. 

f  ^  f"      F 

1       1  _1 

/"  -F  -/'■ 

This  is  understood  by  recollecting  that  F  is  the  focus  for  parallel 
rays,  and  that  the  focus  is  the  inverse  of  the  reflective  or  catoptric 

power  of  the  mirror.  The  rays  which  diverge  from  /'  require  of 
catoptric  power  to  render  them  parallel.  This  diminishes  the  catop- 
tric   power    of    the    mirror    to         • 

=     -  ,the  focal  length  of  /"  is  the  conjugate  focal  distance 

required. 

Example. — The  ophthalmoscopic  mirror  has  a  focus  of  20  cm.,  its  radius  of 
curvature  being  40  cm.     A  caiulle  is  situated  at  30  cm.  in  front  of  it,  and  we  wish 

to  know  the  conjugate  focal  distance: 

F  =  20  cm./'  =  30  cm.  l^  -  l^  =  /,  -    j„  =  ^^  -  ^^  =  J^-/'  =  60cm. 

The  rays  of  the  candle  would  be  rendered  convergent  to  a  point  tiO  cm.  in  front  of 
the  mirror.  The  light  being  placed  at  a  greater  distance  than  the  principal  focus, 
the  rays  are  convergent. 

A  convex  mirror  renders  parallel  raj'S  divergent  as  if  they  came 
from  its  principal  focus,  which  is  negative,  situated  behind  the  mirror,  at 
a  distance  equal  to  one-half  the  radius  of  curvature.  The  image  is 
erect  and  small. 

The  conjugate  focal  distances  for  convex  mirrors  arc  obtained  by 
the  same  formula  as  for  concave^  mirrors,  the  sign  — being  prefixed  to 
F  and  /". 

The  cornea,  by  reflecting  light,  correspomls  to  a  convex  minor,  and 
in  this  relation  is  important  in  ()i)iithalmometry.  'V\\v  principal  focus 
of  the  corneal  mirror  is  about  1  nun.,  tiic  radius  of  curvature  Ix'ing 
7.S2'.)  mm.  The  size  of  the  image  re(U'ct(Ml  from  the  coriK^a  is  pro- 
portional to  the  size  of  the  object  as  the  focus  of  the  corneal  mirror, 
4  mm.,  is  to  the  distance  of  the  object .  A  candle-ffame 20 mm.  in  diam- 
eter, situated  al   100  mm.,  gives  a  corneal  image  whose  size  is  found  in 

this  manner:      lina;:;e:  20::   1 :10!).  "      =  Image  -  O.S  mm. 

20  100 


I 


THE    OPHTHALMOSCOPE  95 

If  the  radius  of  curvature  is  greater,  the  image  is  also  greater;  if  the 
radius  of  curvature  is  smaller,  the  image  is  smaller.  By  this  means 
curvature  ametropia  may  be  measured. 

The  size  of  the  corneal  image  is  so  very  small  that  it  would  not  be 
feasible  to  attempt  direct  measurement  of  it.  If  two  candles  which 
are  separated  some  distance  are  employed  as  an  object,  each  candle 
represents  one  extremity  of  the  object.  The  size  of  the  object  is,  then, 
the  distance  between  the  two  candles;  the  size  of  the  image  is  the  dis- 
tance between  the  reflected  images  of  the  candles.  Suppose  this  dis- 
tance to  be  3  mm.  and  by  means  of  a  double  refracting  prism  two 
images  of  each  candle  are  seen ;  if  they  are  displaced  by  the  prism  exact- 
ly 3  mm.,  so  that  a  straight  line  passes  through  all  the  images,  two  of 
them  must  overhe,  as  the  images  are  3  mm.  apart.  Small  variations  in 
curvature  will  now  be  manifest  if  the  two  images,  which  should  overlie 
exactly,  shoot  past  each  other  or  fail  to  come  together.  The  change  of 
form  in  the  crystalline  lens  during  accommodation  is  proved  by  this 
experiment. 

THE  OPHTHALMOSCOPE 

For  the  purpose  of  studying  the  interior  of  the  living  eye  an  instru- 
ment known  as  the  ophthalmoscope,  the  invention  of  which,  in  1851,  we 
owe  to  the  genius  of  von  Helmholtz,  must  be  emploj^ed.  The  original 
Helmholtz  ophthalmoscope  was  composed,  in  general  terms,  of  three 
thin  glass  plates,  set  in  a  suitable  frame  at  an  angle  of  56  degrees  to  the 
line  of  sight,  by  means  of  which  the  light  was  reflected  into  the  observed 
eye.  With  ois  instrument  the  details  of  the  eye-ground  can  be  stud- 
ied under  a  weak  illumination. 

The  modern  ophthalmoscope  consists  essentially  of  a  concave  sil- 
vered mirror  for  illuminating  the  eye,  and  of  lenses  for  measuring  and 
modifying  its  refraction  (refraction  ophthalmoscope).  The  mirror  is 
perforated,  as  originally  suggested  by  Rente,  and  swings  to  either  side, 
so  that  the  obliquely  incident  rays  may  be  reflected  into  the  eye  with- 
out having  to  tilt  the  entire  instrument,  and  thus  narrow  the  aperture 
and  render  the  lenses  astigmatic.  The  lenses  are  inserted  in  a  disk, 
invented  by  Rekoss,  which  can  be  rotated  in  front  of  the  sight-hole. 
A  plane  mirror,  which  can  be  substituted  for  the  concave  mirror,  is  a 
valuable  addition.  Many  ophthalmoscopes  contain  two  disks,  which 
can  be  used  either  singly  or  in  combination.  This  arrangement  affords 
a  series  of  lenses  from  0.50  to  24  D  concave,  and  from  0.50  to  23  D 
convex,  with  which  the  observer  is  enabled  to  view  distinctly  the  details 
of  the  eye-ground  in  all  forms  of  ametropia.  A  lens  varying  from  13  to 
20  D  accompanies  the  instrument  for  focal  illumination  of  the  cornea 
andlens,  and  for  use  in  the  indirect  method  of  ophthalmoscopy.  Among 
the  many  opthalmoscopes  at  the  student's  disposal,  in  the  author's 
opinion  none  is  better  than  the  Loring  instrument  (Fig.  47).  A.  S. 
Morton's  opthalmoscope  is  an  admirable  one  and  is  much  used. 
Excellent  models  have  been  designed  by  Edward  Jackson,  B.  A. 
Randall,  and  a  number  of  other  surgeons. 


96 


OPHTHALMOSCOPY    AND    SKIASCOPY 


Electric  ophthalmoscopes,  for  which  wo  arc  hirgcly  indebted  to  W.  S. 
Dennett,  are  so  convenient  and  the  illumination  so  satisfactory  both 
in  the  consulting  room  and  at  the  bedside  that  to  a  certain  degree  they 
have  replaced  the  ordinary  instrument.  It,  however,  is  a  mistake  to 
use  an  electric  ophthalmoscope  to  the  exclusion  of  the  other  type 
with  which  the  oplithalmologist  and  the  student  of  ophthalmology 
should  alwaj's  be  accurately  familiar.     The  source  of  illumination  in 


Fig.  47. — LoriiiK's  uijlithalmosoopo,  wiili  tilting  niirior,  cuiiiploti'  disk  of  loiisi'S 
from  —  1  to  —  8  and  0  to  +7,  and  supplemental  iiuadiant  eontaininn  ±  0.5  and  ±  16 
D.     This  affords  60  glasses  or  eomliinations  from   +  23  to   —  24  I). 


the  electric  ophthalmoscope  consists  of  an  electric  l»ull)  in  tlic  cinl  of 
the  handle,  the  light  of  which  is  condensed  by  a  lens  on  a  suitably  tilted 
mirror  which  reflects  it  into  the  eye.  W.  B.  Marple's  electric  ophthal- 
moscopes is,  in  the  opinion  of  the  author,  one  of  the  best  of  these 
iiist  ruments  thus  far  designed  (Fig.  4S)  and  ( "hailes  11.  ^^ay  's  ophthal- 
moscope is  an  admiralile  instrument.  Convenient  models  have  also  l)een 
devised  by  S,  Lewis  Ziegler,  George  Crampton,  II.  ( 'laiborne  and  others. 
Large  demonstrating  ophthalmoscopes  have  a  distinct  value  in  oph- 
thalmos(U)pic  work.  'J'he  (ndl.slrand  ophthabnoscopc  is  the  most  per- 
fect iiistiimient  of  tile  type.  It  is  free  from  annoying  relieetioiis  and 
fiudislies  magnifications  fiom  5  to  40  times  in  nionoeular  and  20  times 
in  bin(»cul;ir  ohserval  ions. 


DIRECT    METHOD 


97 


Direct  Method. — The  rays  from  the  concave  mirror,  somewhat 
converging,  enter  the  pupil  and  are  brought  to  a  focus  in  the  vitreous 
humor.  After  reaching  their  focus  the  raj^s  diverge  again  and  spread 
out  on  the  retina  into  a  circle  of  diffusion.  The  portion  of  the  retina 
thus  illuminated  sends  rays  back  again,  which  pass  through  the  dioptric 
media  of  the  eye  and  are  refracted  to  its  far  point — that  is,  if  the  eye  is 
emmetropic,  they  emerge  parallel  and  would  meet  at  an  infinite  dis- 
tance; if  the  eye  is  myopic,  they  converge  to  their  far  point  in  front  of 


Fig.  48. — Marple's  elec- 
tric ophthalmoscope. 


Fig.  49. — Examination  in  the  erect  image  when  the  eye 
examined  is  hyperopic,  emmetropic,  or  myopic.  In  each 
figure  three  rays  are  shown  emanating  from  a  luminous  point 
on  the  eye-ground.  In  hyperopia  they  diverge  after  leaving 
the  eye;  in  emmetropia  they  are  parallel;  in  myopia  they  con- 
verge. /,  The  posterior  focus;  H,  principal  plane  of  the 
dioptric  system  of  the  examined  eye;  Be,  observer.  The 
ophthalmoscope  is  not  shown  (Haab). 


the  ej'e;  if  the  eye  is  hyperopic,  they  diverge  from  their  far  point  back 
of  the  eye  (see  also  page  112). 

An  observer's  eye,  in  order  to  focus  these  rays,  must  be  adapted  to 
them.  If  the  patient  is  emmetropic,  the  observer's  eye  must  also  be 
rendered  emmetropic.  If  the  patient  is  hyperopic,  the  emmetropic 
observer  must  add  a  convex  glass  to  his  eye,  or  use  his  accommodation, 
in  order  to  make  the  divergent  rays  parallel.  If  the  patient's  eye  is 
myopic,  the  emmetropic  observer  must  place  a  concave  glass  before  his 
eye  to  render  the  convergent  rays  parallel.     If  the  observer  is  ametropic , 


98 


OPHTHALMOSCOPY    AND    SKIASCOPY 


he  must  first  correct  his  ametropia  with  suitable  lenses  (see  also  page 
112).  A  h^'peropic  observer  might  see  distinctly  the  eye  of  a  myopic 
patient,  or  a  myopic  observer  might  see  the  eye  of  a  hyperope.  In 
either  case  the  liyperopia  must  at  least  be  as  great  as  the  myopia. 

In  this  method  the  observer  sees  the  eye  just  as  he  would  see  an 
object  through  a  convex  glass  or  simple  microscope.  The  image  of  the 
eye-ground  is  a  virtual  one — that  is,  it  seems  to  be  behind  the  eye. 
It  is  magnified  and  erect. 

The  fonnatiun  uf  the  image  in  the  direct  method  may  be  understood  by 
examining  Fig.  50. 

Divergent  rays  and  convergent  raj's  have  been  described,  but  al- 
ways in  relation  to  one  point  (see  page  22).  It  is  now  necessary  to 
consider  their  meaning  in  reference  to  an  image. 


Fig.  50. — Diagram  of  the  direct  method  with  the  formation  of  an  upright  image: 
Rays  from  the  source  of  ligiit,  L,  are  received  upon  the  concave  mirror,  M ,  and  converged 
upon  the  obs?rved  eye,  Ohd,  witliin  which  they  cross  and  illuminate  an  area  of  its  fundus. 
From  an  area  A-B  thus  lighted  rays  pass  out  of  the  pupil  (parallel  if  it  be  emmetropic, 
as  here  represented)  through  the  sight-hole  of  the  mirror,   and.  entering  the  obsi^rver's 
eye,  Obr,  are  focuscnl  upon  liis  retina.      An  image  is  there  formed  as  thougli  the  object 
seen  were  at  a  great  distance,  and  the  perceptive  centers  project  it  into  space  as  though 
the  ol)ject  were  at  some  arbitrary  distance  {c.  g.,  25  cm.).      By  the  laws  of  magniticatioa  i 
by  a  simple  lens  the  image  is  embraced  between  the  lines  passing  from  the  optical  center 
of  the  magnifying  lens  (the  refracting  system  of  the  observed  eye),  through  the  extrera-  ' 
ties  of  the  object,  and  has  the    size  A'-B',  A"-B".  etc.,  according  to  tlie  distance  of' 
projection.     In  hyperopia   rays  from   .-l  and  B   would  be  divergent',   and   the  observer  , 
would  ha\-e  to  render  these  rays  parallel  by  a  convex  glass  or  by  using  liis  accommoda- 
tion.    In  myopia  these  rays  vs'ould  be  convergent,  and  a  concave  glass  would  be  renuired 
to  neutralize  their  convergence  and  render  them  parallel  (B.  .\.  Randall). 

-Vii  image  is  composed  of  a  succession  of  points;  each  one  of  these 
points  represents  a  point  in  the  oliject.  From  the  point  in  the  object) 
one  ray  passes  to  the  optical  center  of  the  lens  or  len.'^es,  •ind  maintains 
the  same  direction  after  passing  through  it.  This  i;iy  is  called  the  axial> 
ray:  it  passes  to  the  coi  responding  point  in  the  ini;tu:e.  ( )t her  rays  from 
the  same  point  in  the  ohjecl  (hverge  from  the  axial  ray  at  \aiious  an-i 
gles,  a  bundle  of  these  rays  is  calltMl  a  inncil.  The  size  of  a  ptMicil  is 
determined  by  the  diameter  of  a  lens  or  the  aperture  of  the  pupil. 
The  lens  gives  these  unetiually  diverging  ra>s  a  direction  to  a  conunoD 
point  or  focus.  From  each  point  in  the  illuminated  part  of  the  rtMinS 
a  pencil  of  rays  falls  upon  the  ciystalhin'  lens  .and  <'ornea.     Th(>  siie 


'i 


INDIRECT    METHOD  99 

of  this  pencil  equals  the  diameter  of  the  pupil;  to  form  an  image  each 
pencil  of  rays  must  be  concentrated  into  one  point.  By  diverging 
and  converging  rays  is  meant  the  relation  the  rays  from  each  point 
bear  to  each  other,  not  the  relation  of  rays  from  different  points. 

Size  of  the  Image. — -The  details  of  the  eye-ground  are  considerably 
magnified  in  the  direct  method  of  examination.  In  the  emmetropic 
eye  the  enlargement  is  found  by  the  following  formula:  The  distance 
of  the  retina  from  the  nodal  point  (optical  center)  of  the  eye  is  15  mm. 
The  observer  projects  the  image  which  he  sees  to  the  point  at  which 
small  objects  are  usually  held,  say  250  mm.  The  enlargement  of  the 
disk  is  proportional  to  these  two  distances,  15: 250::  1.5  mm.  :25 
mm.  16.6  =  the  enlargement.  It  is  comparable  to  looking  at  the 
disk  through  the  lens  of  15  mm.  focus,  66  diopters. 

It  is  to  be  remembered  that  the  farther  this  image  is  projected,  the 
larger  it  appears.  In  hyperopia  the  enlargement  is  less  than  this.  In 
myopia,  on  the  contrary',  it  is  greater. 

Indirect  Method. — In  the  indirect  method  of  ophthalmoscopy  a 
real,  inverted  image  of  the  interior  of  the  eye  is  obtained  by  means 
of  a  strong  convex  lens  (object-lens),  the  principle  involved  being  simi- 
lar to  that  of  a  compound  microscope. 

The  observer  holds  the  object-lens  (a  convex  lens  of  about  20  diop- 
ters) close  to  the  patient's  eye,  and,  placing  a  convex  lens  of  5  diopters 
(eye-piece)  behind  the  ophthalmoscope,  throws  the  light  into  the  pupil 
and  moves  his  eye  nearer  to  or  farther  from  the  patient's  eye  until  he 
distinctly  sees  a  vessel  or  a  portion  of  the  nerve — that  is,  a  real  image  of 
the  ej'e-ground  is  formed  by  the  object-lens  at  its  focal  distance  in  front 
of  the  eye.  The  observer  sees  this  image,  in  which  all  the  relations  of 
objects  are  reversed.  His  eye  is  at  a  distance  from  the  image  equal  to 
the  focus  of  the  lens  in  the  ophthalmoscope — viz.,  20  cm. 

The  image  being  inverted,  the  lower  portion  of  it  corresponds  to  the 
upper  part  of  the  ej'e-ground,  and  the  right  side  of  the  image  corre- 
sponds to  the  left  side  of  the  eye.  If  the  observer  moves  upward,  the 
image  moves  downward;  if  the  observer  moves  to  the  right,  the  image 
moves  to  the  left.  Consequently,  the  upper  part  of  the  image  must  be 
viewed  if  it  is  desired  to  see  the  lower  part  of  the  eye-ground,  and  the 
right  side  of  the  image  if  parts  of  the  fundus  to  the  left  are  to  be 
examined. 

A  comparison  between  the  images  as  seen  by  the  direct  and  indirect 
method  may  be  stated  thus:  If,  in  the  direct  method  with  the  disk  in 
view,  the  observer  moves  his  head  to  the  right,  he  brings  into  view  a 
portion  of  the  retina  to  the  left  of  the  disk.  The  disk  now  moves  out  of 
the  field  toward  the  right,  and  disappears  behind  the  right  edge  of  the 
pupil.  The  image,  therefore,  moves  with  the  observer.  If,  in  the  in- 
direct method  with  the  image  of  the  disk  in  view,  the  observer  also  moves 
his  head  to  the  right,  he  sees  the  image  of  the  same  portion  of  the  retina 
as  in  the  direct  method;  but  this  being  to  the  left  of  the  disk,  its  image 
occupies  a  point  to  the  right  of  that  of  the  disk.  The  disk  thus  appears 
to  have  moved  toward  the  left.     The  image,  therefore,  moves  contrary 


100 


OPHTHALMOSCOPY    AND    SKIASCOPY 


to  the  movement  of  the  observer's  head.  Movements  in  other  direc- 
tions are  explained  in  the  same  way. 

The  formation  of  the  inverted  image  in  ophthahiioscopy  may  be 
understood  bj'  examining;  Fig.  51. 

In  hyperopia  and  emmet ropia  a  convex  lens  is  necessary  to  render 
the  rays  convergent.  In  myopia  the  raj'S  emerge  convergent,  and  the 
convex  lens  may  be  dispensed  with  in  the  higher  grades,  though  it  ia 
still  an  advantage  because  it  increases  the  area  of  the  fundus  visible  at 
one  time. 

Size  of  the  Image. — The  enlargement  of  the  image  in  this  method  is 
less  than  it  is  in  the  direct  method,  but  a  larger  portion  of  the  eye- 
ground  is  visible  at  one  time. 

The  size  of  the  real  image  of  the  eye-ground  of  an  emmetropic  eye 
formed  by  the  convex  object-lens  held  at  its  own  focal  length  from  the 
eye  is  determined  by  the  following  formula:  The  size  of  the  disk  is  to 
the  size  of  the  image  as  the  distance  from  the  retina  to  the  nodal  point 


I 


0(V 


Fig.  51. — Diagram  of  the  indirect  incthotl  nivinm  an  inverted  iniape:  Rays  from  the 
source  of  light,  L,  conv'erged  toward  the  observed  eye,  Ohd.  by  the  concave  mirror,  .V, 
are  intercepted  by  the  lens,  Obj,  and  after  coming  to  a  focus  diverge  again  and  light  up 
the  fundus.  From  a  part  of  the  illuminated  fundus  A  B  rays  pass  out  of  the  pupil  to 
be  again  interceptetl  by  the  lens  ()  and  form  an  inverted  real  image  at  its  ai»terior  focus 
A'-Ii'.  This  real  image  is  viewed  by  the  oi  server's  eye  behind  the  sight-hole  of  the 
mirror  with  the  aid  of  a  magnifving  lens,  ()c,  and  is  seen  enlarged,  as  at  A"-B"  (li.  A. 
Randall). 

(1.5  mm.)  is  to  the  focal  length  of  tiie  oljject-glass.  If  the  lens  has  a  fo- 
cal length  of  7.')  mm.,  the  ratio  is  1.')  :  75:  the  enlargement  is  then  5  di- 
ameters. A  lens  of  GO  mm.  focus  would  ecjual  an  enlargement  of  4 
diameters — 15  :  60. 

The  observer  will  see  this  image  under  a  higher  angle  in  pi'oportion 
as  he  comes  closer;  it  will  then  appear  larger.  To  do  this,  he  nnist 
either  use  his  accommodation  or  place  a  convex  lens  (eye-piece)  l)ehiiid 
the  ophthalmoscope.  When  the  ej'e-piece  is  used,  a  visual  image  of  the 
aerial  image,  still  more  enlarged,  is  produced,  just  as  in  the  compound 
microscope.  If  the  object-lens  is  withdrawn  farther  than  its  focal 
length  from  the  obseived  (\ve,  the  image  in  myopia  l)econies  largiM-,  in 
hyperopia  smaller,  and  in  emnietropia  remains  the  same.  If  the  ItMis  is 
brought  closer  to  the  eye,  \\\v  image  becomes  sm;iller  in  myopia  and 
larger  in  hyi)er(tpi;i. 


OPHTHALMOSCOPY  101 

Ophthalmoscopy. — The  investigation  of  the  deeper  structures 
and  interior  of  the  eye  by  means  of  the  ophthahnoscope  may,  therefore, 
be  practised  with  (1)  the  direct,  and  (2)  the  indirect  method. 

1.  The  Direct  Method  (Method  of  the  Erect  or  Upright  Image). — 
The  patient  should  be  seated  in  a  darkened  room  with  his  back  to  the 
source  of  illumination — an  Argand  burner  or  properly  constructed  and 
shaded  electric  light  being  suitable — which  is  placed  behind  and  to  the 
side  of  his  head,  on  a  level  with  the  ear,  the  face  being  in  shadow, 
while  the  rays  of  light  just  fall  upon  the  outer  canthus  of  the  eye. 
This  will  enable  the  observer  to  come  quite  close  to  the  eye  without  in- 
terfering with  the  path  of  the  illuminating  beam.  The  surgeon  sits  at 
that  side  of  the  patient  which  corresponds  to  the  eye  under  examination 
— for  example,  the  right — his  position  being  preferably  on  a  slightly 
higher  level  than  that  of  the  subject.  He  now  takes  the  ophthalmo- 
scope in  his  right  hand,  looks  through  the  sight-hole  with  his  right  eye, 
at  a  distance  of  about  50  cm.  from  the  observed  eye  (the  convex  border 
of  the  instrument  being  in  contact  with  the  concave  margin  of  his 
brow),  meanwhile  keeping  the  other  eye  open,  and  reflects  the  light 
into  the  right  eye  of  the  patient.  If  the  left  eye  is  to  be  examined, 
the  ophthalmoscope  is  held  in  the  left  hand. 

If  an  electric  ophthalmoscope  is  used,  the  instrument  carries  the 
source  of  illumination.  Moreover,  it  is  not  necessary  that  the  room 
shall  be  darkened. 

If  the  patient  looks  directly  into  the  light,  the  pupil,  provided  this 
is  not  dilated  with  a  mydriatic,  will  contract  and  no  satisfactory  view 
is  possible.  He  must  hence  be  directed  to  turn  the  head  slightly  to 
the  right,  and  gaze  into  vacancy  in  the  farthest  limit  of  the  room, 
when  the  pupil  will  be  seen  illuminated  by  a  red  glare — the  reflection 
from  the  choroid  coat — bright  if  the  pupil  is  large,  and  dull  if  it  is 
small.  Xo  details  of  the  fundus  are  as  yet  visible  at  this  distance  (50 
cm.)  unless  a  certain  grade  of  myopia  is  present  or  a  considerable  de- 
gree of  hyperopia  (see  page  112). 

The  beginner  should  now  practise  keeping  the  light  steadily  in 
position,  and  may  estimate  the  success  of  his  endeavor  by  observing 
the  glare  in  the  pupil.  If  this  changes  in  color  or  disappears,  the  light 
has  shifted  from  its  proper  position  because  the  examiner  has  failed  to 
retain  his  elbow  in  close  contact  with  his  side,  and  allowed  it  to  move 
outward  and  away  from  his  body,  the  head  meanwhile  being  bent  to 
one  or  the  other  side  of  the  vertical  position  it  should  assume  in  a  direct 
line  with  that  of  the  subject — feature  to  feature.  This  may  be  under- 
stood bv  observing  the  two  accompanying  illustrations  (Figs.  52  and 
53). 

Having  gained  control  of  the  hght,  the  observer  gradually  ap- 
proaches the  eye  of  the  patient,  taking  care  that  the  red  glare,  which  is 
tinted  slightly  yellow  on  the  nasal  side,  marking  the  position  of  the  op- 
tic papilla,  remains  unaltered,  and  comes  as  close  as  possible — within  1 
inch  or  even  nearer.  If  the  maneuver  has  been  successful,  and  the  light 
directed  slightlv  toward  the  nasal  side,  the  most  prominent  feature 


102 


OPHTHALMOSCOPY    AND    SKIASCOPY 


Fig.  52. 


-Ophthalmoscopic  examination.     Method  of  the  upright  image.     Observer 
in  the  correct  position. 


Fia.   53. — Ophthalmoscopic   cxaniination.      Mi'thod   of   the   upright    iiiiiigc.     Observer 

in  an  incorrect  position. 


in  the  pyp-ciround— thr  optic  norvc"^ — will  t'oinc  into  view;  or  ii  ictimil 
vossol  may  first  he  inanifcst,  and  sliould  be  followed  to  the  papilla  as  a 
stream  w(nild  he  to  its  source. 


LOCATION     OF    OPACITIES    IN    THE    TRANSPARENT    MEDIA    103 

Before  proceeding  to  study  the  details  of  the  fundus  the  student 
should  make  certain  preliminary  examinations. 

(a)  Examination  of  the  cornea,  anterior  chamber  and  lens 
by  transmitted  light  is  made  by  placing  a  +  7  D  or  16  D  lens  behind 
the  mirror,  coming  close  to  the  eye — that  is,  until  the  object  to  be 
examined  is  within  the  focal  distance  of  the  lens  employed,  and  reflect- 
ing the  light  into  the  eye  in  the  manner  alread}^  described. 

A  foreign  body  on  the  cornea,  a  macula,  a  deposit  on  the  posterior 
layer  of  the  cornea,  or  an  opacity  in  the  lens  appears  as  a  black  object 
against  the  red  background,  in  contradistinction  to  its  appearance  in 
its  true  color  under  oblique  illumination  (see  page  51). 

At  the  same  time  the  mobihty  of  the  iris  should  be  tested,  and  an 
observation  made  as  to  whether  the  iris  reacts  promptly  and  evenly 
under  the  influence  of  the  light  directed  into  the  pupil  at  various  angles. 
Iritic  precipitates  in  the  anterior  chamber  and  attachments  to  the 
lens  may  be  observed  by  this  method  and  by  holding  the  ophthalmo- 
scopic mirror  practically  at  right  angles  to  the  eye  the  angle  of  the 
anterior  chamber  can  be  studied. 

(6)  Examination  of  the  vitreous  is  made  by  reflecting  the  hght 
with  the  concave  or,  better,  the  plane  ophthalmoscopic  mirror,  from  a 
distance  of  30  cm.  into  the  eye,  while  this  is  moved  in  various  directions 
so  as  to  bring  into  view  opacities  which  have  a  lateral  situation  or  which 
have  sunk  to  the  bottom  of  the  vitreous  chamber. 

Vitreous  opacities  and  detached  retina  are  seen  in  the  erect  position 
if  the  observer  is  sufficiently  far  away,  because  they  are  within  his 
range  of  accommodation.  Small  vitreous  opacities  appear  dark; 
larger  ones  have  a  gi'ayish  appearance.  If  he  approaches  closely,  he 
must  place  behind  the  mirror  a  convex  lens,  in  the  manner  just  de- 
scribed, to  bring  them  into  focus,  and  should  always  use  this  method. 

(c)  Location  of  Opacities  in  the  Transparent  Media. — If,  the 
observer  using  the  ophthalmoscopic  mirror  in  the  manner  described  in 
the  previous  paragraph,  an  opacit}'  is  seen  to  be  freely  movable,  it  must 
be  in  the  vitreous.  Should  the  opacity  move  onl}^  with  the  movement 
of  the  eye,  but  not  spontaneously,  it  probablj^  is  situated  in  the  cornea 
or  in  the  lens,  although  it  may  be  present  in  the  vitreous  in  the  form 
of  a  fixed  opacity.  In  these  circumstances  a  differential  diagnosis  can 
frequent!}^  be  made  by  means  of  oblique  illumination..  Should  this 
method  prove  insufficient,  the  situation  of  the  opacity  may  be  ascer- 
tained by  means  of  its  parallactic  movement  in  relation  to  the  border 
of  the  pupil.     Fuchs  states  the  rule  as  follows: 

The  observer  looks  directly  forward  into  the  eye  and  notes  the 
position  of  an  opacity  within  the  pupillar\^  space.  Next,  while  the 
patient  keeps  his  eye  entirel}'  quiet,  the  examiner  slowly  moves  from 
side  to  side  and  observes  if  the  opacity  retains  or  does  not  retain  the 
same  position  in  the  pupillary  space.  If  the  opacity  retains  its  posi- 
tion unchanged,  it  hes  in  the  pupillary  plane  upon  or  immediately 
under  the  anterior  capsule  of  the  lens.  If  it  does  not  retain  its  original 
position,  it  is  situated  in  front  of  or  behind  this  plane — in  front  of  the 


104  OPHTHALMOSCOPY   AND   SKIASCOPY 

plane  if  the  opacity  moves  in  a  diroction  opposite  to  the  direction  of  the 
movement  of  the  observing  eye,  and  behind  the  plane  if  the  opacity 
moves  in  the  same  direction  as  the  observing?  ej'e.  The  quicker  the 
change  of  position  takes  place,  the  farther  is  the  opacity  removed  from 
the  pupillary  plane. 

Instead  of  proceeding  in  this  manner,  the  observer  may  retain  his 
position  unaltered  and  cause  the  patient  to  move  his  eye  in  various 
directions. 

When  an  opacity  is  far  back  in  close  relation  with  the  retina,  its 
location  may  be  judged  by  noting  its  relation  to  the  movement  of  the 
retinal  vessels.  How  far  forward  it  lies  in  the  vitreous  may  l)e  accu- 
rately measured  by  means  of  convex  lenses  (see  page  107). 

Having  ascertained  that  the  media  are  clear,  and  having  approached 
sufficiently  close,  the  details  of  the  fundus  oculi  are  brought  into  view 
and  studied  seriatim. 

If  either  surgeon  or  patient  is  myopic,  the  necessary  concave  lens 
which  corrects  the  error  must  first  be  placed  in  position;  while,  if  hyper- 
opia exists,  the  fundus  is  visible  without  the  aid  of  a  glass,  provided  the 
hyperopia  is  not  in  excess  of  the  power  of  accommodation. 

Beginners, however,  often  fail  to  obtain  an  image  of  sharp  definition, 
owing  to  inability  to  relax  accommodation,  and  succeed  in  seeing  the 
details  clearly  only  through  a  concave  glass.  The  power  of  relaxing  the 
accommodation  comes  with  practice. 

The  optic  nerve  appears  as  a  nearly  round  or  slightly  oval  disk, 
situated  toward  the  nasal  side,  varying  in  color  from  a  grayish  pink  to 
a  more  decided  red,  the  tint  being  most  marked  upon  the  nasal  half, 
while  the  center  is  occupied  by  a  whiter  patch — the  "light  spot" — 
marking  the  position  of  the  entrance  and  emergence  of  the  retinal 
vessels.  The  general  tint  of  the  optic  disk  varies  with  the  age  and  com- 
plexion of  the  patient  and  with  the  intensity  of  the  color  of  the  sur- 
rounding eye-ground. 

The  papilla  is  bounded  by  two  rings.  The  outer  one,  dark  colored, 
usually  incomplete  or  existing  only  as  a  slight  crescent  of  pigment  u])on 
one  or  the  other  side,  is  the  choroidnl  rihcf,  and  represents  the  l)order 
of  the  choroidal  coat,  where  this  is  piercetl  by  the  oi)tic  nerve,  ^^'ithin 
this  is  a  faint  white  stripe,  more  distinct  in  elderly  people,  the  ,scUial 
ring,  which  indicates  the  rim  of  the  sclerotic  coat,  or,  according  to 
Loring,  the  coimective-tissue  ehMuents  of  the  inner  sheath  of  the  nerve 
{connective-tissue  ring).  "^Fhe  choroiilal  ring  is  often  imperfectly  pro- 
fluced  or  entirely  al)sent  and  the  scleral  ring  may  l)e  faintly  marked, 
visible  only  on  one  side  of  the  disk  and  in  some  eyes  is  scarcely  if  at  all 
visible. 

The  centi'al  white  patch  may  l>c  noticeable  only  by  contrasting  it 
witii  the  color  of  its  surroundings.  oi-  it  may  be  a  distinct  excavation, 
occupying  the  c(Miter  of  the  disk,  and  having  sharp  borders,  one  of 
which  often  shelves  slightly  outwaid.  This  is  th(>  ithysiologic  cup.  and 
is  the  space  left  by  the  radiation  of  the  nerve-fibers  toward  the  retina, 
having  a  floor  of  white  color,  liecause  it  is  ('(tinposed  of  the  iiiteilaeing 


Plate  I. 


The  normal  fundus  of  the  right  eye  examined  by  the  direct  method 
of  ophthalmoscopy. 


THE   BLOOD-VESSELS  105 

opaque  fibrous  tissue,  or  lamina  cribrosa,  which  underhes  the  optic 
papilla.  It  is  often  stippled  in  appearance,  owing  to  the  lack  of  light 
reflected  by  the  non-medullated  nerve-fibers,  which  pass  through  the 
spaces  of  the  lamina.  According  to  Schoen,  the  so-called  physiologic 
excavations  are  due  to  dragging  of  the  vaginal  processes  of  the  optic 
nerve  and  lamina  cribrosa  from  overexertion  of  the  accommodation, 
and  hence  are  found  in  adult  eyes  more  commonly  than  in  the  eyes  of 
children.  They  are  usually  but  not  always  bilateral,  and  one  may  be 
larger  than  the  other.  Schweigger  traced  hereditary  transmission  in 
some  large  physiologic  excavations,  but  doubted  if  they  were  associated 
with  any  particular  refractive  condition  of  the  eye. 

The  BIood=vessels. — From  the  central  light-spot  the  principal 
retinal  arteries  emerge,  and  into  it  the  chief  venous  trunks  empty. 
Usually  one  venous  and  one  arterial  stem  pass  directly  upward  and 
downward,  and  on  the  edge  of  the  disk,  or  a  short  distance  from  it, 
each  divides  into  two  branches.  Sometimes  this  division  has  taken 
place  in  the  axis  of  the  nerve  behind  the  lamina,  and  two  arteries  and 
two  veins  appear  directly  in  the  central  opening  of  the  papilla,  or 
poms  opticus.  The  arteries  traverse  the  surface  of  the  eye-ground, 
dividing  dichotomously  into  numerous  branches,  and,  passing  above 
and  below,  spread  in  greater  size  and  number  over  the  temporal  half 
of  the  retina,  sending  small  branches  toward  the  macula;  and  in 
smaller  size  and  less  number  over  the  nasal  side.  Fine  branches 
arising  from  the  central  large  trunks,  or  springing  directly  from  the 
nerve,  pass  outward  and  inward,  and  also  undergo  numerous  divisions. 

The  veins  pass  over  the  eye-ground  in  the  same  general  direction 
as  the  arteries,  and  in  close  relation  to  them,  emptying  usually  by 
means  of  two  large  branches  into  the  center  of  the  disk. 

According  to  the  situation  of  the  vessels,  they  are  named,  respec- 
tively, upper  and  lower  temporal  artery  and  vein,  upper  and  lower 
nasal  artery  and  vein,  and  macular  and  nasal  arteries  and  veins. 

The  veins  are  dark  red  in  color,  contrasting  with  the  bright,  natural, 
blood-red  color  of  the  arteries.  They  are  slightly  tortuous,  and  larger 
than  the  arteries  in  the  proportion  of  3  to  2.  The  difference  in  color 
between  veins  and  arteries  is  most  marked  in  the  major  branches.  In 
the  finer  twigs,  after  four  or  five  divisions,  the  distinction  between 
arteries  and  veins  is  often  possible  only  by  tracing  them  to  their  source. 

Each  vessel  usually  presents  a  double  contour,  owing  to  a  bright 
stripe  which  passes  along  the  center,  leaving  a  red  line  on  either  side. 
This  so-called  light-reflex  has  been  ascribed  to  a  condensation  by  the 
refractive  action  of  the  blood  column  of  the  rays  of  light  which  have 
passed  through  the  vessel  from  in  front,  and  have  been  reflected  back 
slightly  from  the  posterior  wall,  but  chiefly  from  the  underlying 
tissues.'     It  is  more  marked  upon  the  arteries  than  upon  the  veins, 

*  The  cause  of  the  light  streak  was  usually  attributed  to  reflection  from  the 
anterior  surface  of  the  vessel  wall  or  the  anterior  surface  of  the  blood  column,  until 
Loring  maintained  that  the  refraction  of  light  was  the  chief  cause  of  the  phenome- 
non.    A.  E.   Davis  endeavored  experimentally  to  confirm  Loring's  conclusion. 


JQ(;  OPHTHALMOSCOPY    AND    SKIASCOPY 

and   indeed,  is  often  absent  as  tl>e  latter  cross  the  disk  being  visible 
in  a  mTnor  degree  when  they  Ue  at  some  d.stanee  m  'ho  refna 

p"  a°m«.-The  retinal  arterial  pulse  has  been  elassifiod  by  Ballan- 
tyne^  follows:  (1)  Locomotor  pulse,  that  is.  a  rhythm.e  d-P''^;"™^;! 
of  the  arterv  almost  synchronous  w.th  the  eard.ae  systole,  (2)    be 
exmmae  puhe,  being  a  broadening  of  the  blo<,d  eohnnn;   (3)   the 
rnJZr^mle  being  a  variation  in  the  tint  of  the  optic  d.sk,  and  (4) 
Ztlu     pu,se,  a  rhythmic  collapse  or  disappearance  of  the  arterj-^ 
obse^^d    n  glaucoma,  and  produced  by  pressure  on  the  eyeball,  and 
sometimes  called  the  collapsing  pulse.    The  locomotor  pulse  is  ph>  .o- 
lode  aTleast  not  pathologic;  the  expansile  pulse  may  occur  m  healthy 
persons   or  may  be  associated  with  aortic  insufficiency;  the  eapdlary 
S        seen  with  aortie  regurgitation;  the  pressure  or  collapsing 
CZ  is  observed  in  glaucoma,  in  aortic  regurgitation,  and  m  syncope. 
■^Spontaneous  pulsation  in  the  veins  is  -^.f^-^"-^"' ph™™'"'""^ 
Lang  and  Barrett  found  it  in  73.8  per  cent.;  Veasey,  in  o8.3.  and  the 
author  ta  62.1  per  cent,  of  their  examinations.     It  may  be  produced  by 
a  sUgM  pressure  upon  the  globe.     The  spontaneous  ptllse  is  due  to  a 
:ommunication  of  fhe  arterial  pulsation  to  the  j-e.n,  -  h-^  -s^    1^ 
side  bv  side  in  the  optic  nerve,  or  may  be  explan  ed  b>  the  theory  o 
Donders   that  during  the  systole  of  the  heart  ^diastole  "f  'he  ■■ennal 
arteries)  an  increased  tension  in  the  vitreous  is  communicated  to  the 
wills  of  the  retinal  veins,  especially  the  larger  ones,  at  their  exit  from 
Theeve  where  the  least  resistance  is  offered,  obstructing  the  flow  of 
llood  and  compressing  their  lumen.     The  blood  coming  from  the  capil- 
larTes  overcomes  this  resistance  and  the  vessels  regain  their  cahber. 
aUernate  cXpse  and  distention  thus  being  produced.    Aecordmg  to 
Turk   the  venous  pulse  is  due  to  a  continuation  of  the  arterial  pulse- 
wave  through  the  capillaries  into  the  veins.  ,     , ,    .  ,  ,„ 
Phvsiologic  Variations.-The  popiUa.  instead  of  being  round  or 
slightly  oval,  with  a  vertical  long  axis,  is  often  distinctly  irregular  in 
out  ne   or  has  its  long  axis  in  a  horizontal  or  oblique  direction.     Its 
outer  haH  may  be  embraccl  by  a  crescent  of  greater  or  less  choroida 
changes    the  so-ealled  com,.-  or  crescent.     .\  congenital  crescent   of 
white  appearance,  the  underlying  conns,  may  sometimes  be  «'on  below 
see  page  517),  and  occasionally  is  very  broad,  approximating  in 
ippearance  a  coloboma  of  the  nerve-sheath  (see  page  5  6). 

The  physiologic  cup  varies  in  size,  area,  and  dep  h.     No  in.dl. 
situat<'l  on  the  "emporal  side,  it  may  be  a  deep  pi.    funnel  shaped 
w        overlruigmg  margins  over  which  the  vessels  sharply  bend,  or 
verv  shall'lw  all.  1  clish-like,  sloping  to  the  temporal  side,  or  <lecp  and 
Shan  Iv  marke.:  on  its  inner  side,  but  sha.hng  outward. 

The  distribution  of  the  vessels  is  subje.-t  lo  nunu.rous  varia  ions-  so 
much  so  that  it  wouhl  be  difficult  to  ftnd  ,t  the  same  i„  any  Iwo  e>es. 

Story  roieet,  ..ori„.'«  "";;;7;,;;;;;;,»-i;;- :r  i^- ,;TtiMo:,n;;;';he';.M;:r£ 
■:;^:^::^::^^zrz;i:!:^tt;:,z^ ...J. »-» .i.^  „..„.. 


PHYSIOLOGIC   VARIATIONS 


107 


The  usual  departure  from  the  ordinary  type  is  the  one  ah-eady  referred 
tOj  in  which  four  major  branches  (two  arteries  and  two  veins)  appear  at 
the  center  of  the  porus,  instead  of  two  large  branches  which  later 
divide  at  or  near  the  margin  of  the  disk.  Anomalies  of  the  veins  upon 
the  disk,  in  the  form  of  unusual  bifurcations,  are  occasionally  seen. 
Division  of  the  vein  just  before  entering  the  disk;  division  at  the 
margin;  the  formation  of  a  vascular  circle  and  final  reunion  in  a  single 
vessel;  and  anastomosis  of  the  central  vein  with  an  aberrant  vein,  or 
one  which  has  penetrated  the  inner  side  of  the  disk,  have  been  described 
(Randall).  The  veins  are  normally  more  tortuous  than  the  arteries. 
Both  sets  of  vessels  present  this  appearance  in  marked  degree  in 


'xA5^. 


Fig.  54. — Extreme  congenital  tortuosity  of  vessels.     Note  the  breadth  of  the  scleral 

ring. 

certain  pathologic  conditions,  but  also  occasionally  as  an  anomaly 
without  such  significance  (Fig.  54).  Again,  the  vessels  may  stand 
forward  from  the  disk  in  a  high  curve,  or  twine  around  each  other,  as 
we  sometimes  see  two  stems  on  a  vine.  Marked  enlargement  of  the 
anastomoses  about  the  nerve  entrance,  which  anastomoses,  according 
to  Leber,  connect  the  retinal  and  ciliary  vascular  systems  at  the 
level  of  the  papilla  and  at  the  level  of  the  choroid,  have  been  described 
by  George  Coats. 

An  anomaly  of  not  infrequent  occurrence  (7  to  10  per  cent,  of 
examined  eyes)  is  a  cilioretinal  vessel,  usually,  according  to  Elschnig,  an 
artery,  which  appears  at  the  temporal  border  of  the  disk,  then  arches 
outward  or  away  from  the  papilla,  enters  the  retina,  and  pursues  a  gen- 


108  OPHTHALMOSCOPY    AND    SKIASCOPY 

eral  course  toward  tho  inacvila.  A  large  cilioretinal  vessel  may  take 
the  place  of  one  of  the  temporal  arteries.  According  to  Elschnig.  a 
cilioretinal  vessel  may  be  a  primary  Ijranch  of  a  ciliary  artery  which 
pierces  the  sclera  obliquely,  without  sending  a  branch  to  the  choroid, 
and  then  enters  the  intrascleral  or  intrachoroidal  part  of  the  optic 
nerve,  or  an  offset  of  a  ciliary  vessel  which  primarily  enters  the  choroid, 
where  it  divides,  and  one  branch  passes  on  into  the  retina  and  produces 
the  anomah'  in  question.  Cilioretinal  veins  may  ari.><e  from  the 
choroidal  vascular  system.  Opticociliary  vessels  are  uncommon. 
They  are  practically  always  veins,  only  two  instances  of  opticociliary 
arteries  having  been  reported  (Coats).  They  pass  from  the  central 
vessels  to  the  disk  border,  where  they  disappear  under  the  retina  into 
the  choroid.  In  reporting  a  case  of  this  character  W.  T.  Shoemaker 
regards  the  anomalous  vessel  as  representing  an  aberrant  choroidal 
vein. 

The  Retina. — Inasmuch  as  the  retina  is  practically  transparent,  a 
study  of  this  membrane  is  hardly  possible  without  a  consideration  of 
its  underlying  pigment  epithelium  of  the  choroid  and  even  of  the 
sclera. 

In  certain  persons,  especialh'  of  dark  complexion,  the  retina  assumes 
a  grayish  tint  in  the  neighborhood  of  the  papilla,  most  marked  upon 
its  nasal  half.  This  faint  opacity  is  slightly  streaked,  the  striations 
indirectly  corresponding  to  the  expansion  of  the  optic  nerve-fibers. 
Eyes  long  subjected  to  the  strain  of  uncorrected  ametropia  furnish  an 
exaggerated  picture  of  this  appearance,  which,  if  at  all  extensive  and 
associated  with  similar  opacities  along  the  lines  of  the  vessels,  assume* 
pathologic  importance  (see  Retinitis).  In  old  people  the  retina  is  less 
transparent  than  in  those  of  younger  years;  the  vessels  are  often 
smaller  and  the  nerve-head  paler. 

In  the  eye-ground  of  young  subjects,  particularly  along  the  line  of 
the  vessels,  numerous  wave-like,  glistening  retlexos  may  be  seen  to 
follow  one  after  another  with  the  slightest  movements  of  the  oi)hthal- 
moscopic  mirror.  The  effect  is  similar  to  the  shimmer  seen  on  the  sur- 
face of  certain  silks,  and  has  been  (l(>signated  by  iMiglish  writers  shot- 
silk  retina.  It  is  unusual  to  find  the  plKMiomenon  in  individuals  over 
thirty,  its  occurrence  being  marketl  in  direct  proportion  to  the  youth 
of  the  subject.     This  appearance  is  without  pathologic  significance. 

Macula  Lutea. — Al)()ut  two  disks'  diameter  to  the  outer  side  of 
the  papilla,  and  slightly  below  the  horizontal  meridian.  tluMe  is  a  cir- 
cular or  slightly  oval  spot,  e(|ual  in  area  to  the  end  of  tlu>  ojitic  nerve, 
darker  in  color  than  the  surrounding  fundus,  uncrossed  by  any  visible 
ictiiial  vessel,  but  toward  which  the  finer  twigs  of  the  major  branches 
pass,  fringing  its  boundary.  This  region  is  the  macula  liilcn,  or  ydlow 
s/)ot,  an<l  is  that  portion  of  the  eye-ground  concerned  with  the  functions 
of  direct  vision. 

Its  center  is  occupied  l)y  l\\('  /(>!•( nl  r(Jti.r,  which  marks  the  edge  of 
iho  fovea  centralis,  :i?i(l  wlmli  ni.iv  :i|)pe;ii-  ;is  ;i  spot  of  light,  a  small 
circle  with  re(l(lisli  ceiitei-,  ;i  sliil'tiiig  cicseeiit ,  oi'  a  shining  line.      This, 


i 


II 


MACULA    LUTEA  109 

in  turn,  is  surrounded  by  a  dark  area  (the  dark  spot  of  the  macula), 
sometimes  containing  a  number  of  brownish-black  or  light  colored  or 
even  glistening  granules,  which  have  been  mistaken  for,  and  described 
as,  Gunn's  dots.^  They  have  no  pathologic  significance.  Finally, 
the  margin  of  the  macula  is  bounded  by  a  glistening  whitish  ring  or 
halo  (macular  reflex). 

The  method  of  examination  determines  whether  all  these  character- 
istics of  the  macula  lutea  can  be  observed.  They  are  fairly  constant, 
however,  with  the  exception  of  the  halo,  and  are  notable  in  j^oung 
children.  Ordinarily,  the  macular  ring  is  best  seen  in  the  inverted 
image  in  young  eyes,  where  it  is  apt  to  assume  an  oval  shape,  that  is,  a 
delicate  white  curved  line  forms  a  horizontal  oval,  approximately  the 
size  of  the  papilla,  which  encloses  a  brownish-red  area  containing  a 
bright  dot  in  its  center.  According  to  Lindsay  Johnson,  even  in  the 
upright  image,  if  the  source  of  illumination  be  gradually  lowered,  a 
time  is  arrived  at  when  more  light  is  reflected  from  the  macula  than 
from  the  general  fundus,  and  at  that  moment  the  ring  appears.  In 
elderly  people  the  region  usually  cannot  be  well  recognized  except  by 
the  absence  of  vessels  and  its  darker  color,  but  even  in  them  careful 
focusing  will  not  infrequently  reveal  the  foveal  reflex.  In  albinos  it  is 
still  more  difficult  to  define  this  area. 

Although  no  vessels  visible  to  the  opthalmoscope  cross  the  macula, 
except  as  an  anomaly  (Randall,  Johnson),  the  region  is  abundantly 
supplied  with  capillaries,  which  can  be  shown  by  artificial  injection, 
which  surround  the  fovea  in  a  close  loop,  but  do  not  occupy  it.  The 
student  may  find  the  region  difficult  to  stud}'  because  the  light  falling 
upon  it  causes  the  pupil  to  contract,  the  view  being  further  hindered  by 
the  corneal  reflex.  Hence  the  pupil  should  be  dilated,  when  the  macula 
may  be  brought  into  view  by  requiring  the  patient  to  look  directly  into 
the  ophthalmoscopic  mirror,  or  may  be  found  by  turning  the  light  out- 
ward from  the  lower  edge  of  the  disk.  The  region  should  always  be 
studied  with  the  utmost  care. 

The  appearances  in  the  macula  depend  partly  upon  the  disposition 
of  the  layers  of  the  retina  in  this  region.  At  its  margin  the  retina  is 
much  increased  in  thickness  by  an  extra  development  of  the  layer  of  the 
ganglion  cells,  while  the  fovea  is  produced  by  the  hollowing  out  of  the 
center  fo  the  macular  region.  The  macular  reflex,  or  ring,  therefore, 
may  be  considered  as  a  reflection  arising  from  the  thickened  macular 
circumference,  and  the  foveal  reflex  as  a  reflection  from  the  edge  of  the 
fovea.  The  variations,  according  to  Johnson,  are  due  to  the  direction 
and  the  shape  of  the  sloping  sides  of  the  pit,  but,  according  to  Dimmer, 

'Gunn's  dots  ("Crick"  dots)  were  thus  described  bj^  Marcus  Gunn:  "Very 
minute  yellowish-white  shining  dots  for  some  distance  around  the  disk,  especially 
to  the  nasal  side  and  below.  In  distribution  these  dots  are  remarkably  equidistant 
from  each  other  and  are  situated  anteriorly  to  the  largest  retinal  blood-vessels, 
each  being  less  than  one-fifth  of  the  diameter  of  a  large  vessel;  the  outline  of  the 
disk  is  rather  indistinct,  the  large  veins  full  and  somewhat  tortuous."  Those 
first  described  occurred  in  the  eyes  of  members  of  the  same  family.  Their  nature 
is  unknown.     Dread  of  light  ma}'^  be  a  conspicuous  symptom. 


110  OPHTHALMOSCOPY    AND    SKIASCOPY 

depend  upon  th(>  kind  of  ophthalmoscopic  mirror  whicli  is  employed, 
the  reflex  being  the  inverted  imajre  of  the  center  of  the  mirror.  Accord- 
ing to  Piersol,  the  color  of  the  macula  depends  upon  the  presence  of  a 
yellowish  pigment  within  the  layers  internal  to  the  visual  cells,  the 
latter  elements  remaining  colorless;  in  consequence  of  this  arrangement 
the  fovea,  in  which  the  neuro-epithelium  alone  exists,  is  devoid  of  pig- 
ment, and,  therefore,  appears  as  a  light  spot  within  the  colored  area. 
The  dark-brown  spot  of  the  macula  is  generally  believed  to  depend  upon 
the  thinning  of  the  retina  at  this  spot,  with  a  more  decided  pigmenta- 
tion in  the  epithelium.  Dimmer,  however,  thinks  that  it  is  also  pro- 
duced by  absence  of  the  slight  veiling  of  the  retina  at  this  point,  whicli 
is  manifest  in  the  surrounding  more  compact  layers. 


'  /Ax 


r^^-— ^ 


•I 


Fig.  55. — Minute  vascularization  of  the  macular  region  as  shown  by  entoscopic  study 
of  the  right  eye  illuminated  through  a  moving  pin-hole.  (Randall,  American  Text  Book 
of  Diseases  of  Eye,  Ear,  Nose  and  Throat.) 

The  Choroid. — The  bright  glare  which  illuminates  the  pupil  when 
the  light  is  thrown  into  it  from  the  ophthalmoscopic  mirror,  and  de- 
velops into  the  uniform  red  color  of  the  fundus,  when  this  is  brought 
into  view,  arises  from  the  choroid.  The  rays  of  light  pass  through  the 
transparent  retina  to  its  pigment  epithelium,  which  in  ophthalmoscopic 
work  is  usually  accredited  to  the  choroid,  and  in  part  are  absorbed  and 
in  part  reflected.  The  greater  the  quantity  of  the  pigment,  the  greater 
the  amount  of  absorption,  so  that  the  color  of  the  eye-ground  depends 
upon  th(;  ch'gree  of  saturation  in  this  epitiieliuni,  and  varies  from  an 
almost  slaty  color  in  the  dark-skinned  races  to  a  dark-reil  in  persons  of 
blond  complexion.  A  light  yellowish-red  or  brownish  color  is  often 
evident. 

In  very  fair  people  th(>  diminisluMl  amount  of  pigment  contained  io 
I  lie  pigment  epilheHum  and  the  imperfect  (levelopm(>nt  of  pigmeiit- 
(tejls  of  tjie  choroid  exposo  the  largei'  choroid  vessels,  which  ar»'  evident 


DETERMINATION   OF  REFRACTION  BY  THE   OPHTHALMOSCOPE     111 

as  a  meshwork  of  tortuous  red  bands  with  intervening  spaces  of  lighter 
or  darker  color  (intervascular  spaces),  and  which  are  distinguishable 
from  the  retinal  arteries  and  veins  by  their  flat  appearance  and  absence 
of  the  light  streak.  An  eye-ground  of  this  appearance  is  known  as  the 
tessellated  fundus;  it  must  be  not  mistaken  for  choroiditis  (page  374). 
A  nearly  perfect  exposure  of  the  choroidal  vessels  is  seen  in  albinos 
{albinotic  fundus).  The  intervascular  spaces  are  lighter  than  the 
vessels,  because  the  sclera  is  visible. 

It  is  not  usually  possible  with  the  ophthalmoscope  to  differentiate 
the  arteries  and  veins  of  choroidal  vascular  system,  although  the  latter 
are  of  greater  size,  and,  near  the  equator  of  the  eye,  converge  toward 
the  venae  vorticosse,  being  separated  by  larger  and  longer  spaces.  In 
decided  brunettes  these  spaces  are  more  deeply  tinted  than  the  vessels, 
which  appear  "like  light  streams  separated  by  dark  islands"  (Nettle- 
ship).  A  fair  general  idea  of  what  tint  may  be  expected  in  the  fundus 
may  be  obtained  by  observing  the  color  of  the  patient's  hair. 

All  the  details  of  the  eye-ground  maj"  be  studied  with  greater  ease 
through  a  dilated  pupil,  and,  on  beginning  his  studies,  the  student  may 
with  propriety  employ  a  mydriatic — euphthalmin,  cocain,  or  homa- 
tropin,  not  atropin— provided  no  signs  of  glaucoma  are  present  and 
at  the  conclusion  of  the  examination  a  drop  of  one-half  per  cent,  solu- 
tion of  pilocarpin  is  instilled.  Having  acquired  a  knowledge  of  the 
normal  appearance  thus  seen,  he  must  now  practise  with  the  undilated 
pupil. 

The  disk  and  macula  having  been  studied,  the  peripheral  parts  of 
the  eye-ground  should  be  examined  by  throwing  the  hght  inward, 
upward,  and  downward,  the  head  of  the  observer  being  moved  corre- 
spondingly to  comply  with  the  changed  direction  of  the  mirror.  Even 
where  the  central  part  of  the  fundus  presents  the  usual  characteristic 
red  tint,  the  choroidal  vessels  are  frequently  exposed  in  the  periphery, 
presenting  the  appearance  just  described,  and  having  no  clinical 
importance. 

Ophthalmoscopy  with  Red=free  Light. — That  changes  in  the 
color  of  the  eye-ground  are  produced  by  variations  in  the  color  of  the 
source  of  the  illumination  employed  in  the  examination  is  well  known. 
Thus  Mayou  working  with  a  mercury  vapor  lamp  noted  that  the  general 
color  of  the  fundus  was  green,  the  optic  disk  white  in  its  center  and 
green  at  its  edges,  the  retinal  vessels  purple  and  the  choroidal  vessels 
a  deeper  purple.  ]More  recently  Vogt,  using  a  yellow-blue  light, 
obtained  through  a  filter  which  cut  out  all  red  rays,  has  demonstrated 
that  the  color  of  the  living  retina  at  the  macula  is  yellow,  the  optic  disk 
white  or  greenish,  the  small  vessels  black  and  that  retinal  reflexes  are 
visible  at  all  ages ;  even  the  smallest  retinal  hemorrhages  are  strikingly 
evident.^ 

Determination  of  Refraction  by  the  Ophthalmoscope. — The 
estimation  of  the  refraction  of  the  eye  by  means  of  the  ophthalmoscope 
results  in  either  a  qualitative  or  a  quantitative  determination. 
1  American  Journal  of  Ophthalmology  Vol.  ii,  No.  2,  1919. 


112  OPHTHALMOSCOPY    AND    SKIASCOPY 

The  fornuM-  is  obtained  in  the  following  manner:  Hold  the  ophthal- 
moscope 30  to  50  cm.  from  the  patient's  eye,  and,  looking  through  the 
central  aperture  of  the  mirror,  unaided  by  a  glass,  observe  if  any  vessels 
come  into  view.  Their  appearance  means  that  the  eye  is  either  hyper- 
opic  or  myopic.  Now  move  the  head  from  side  to  side,  and  note  if  the 
vessels  move  apparently  in  the  same  or  in  a  direction  opposite  to  the 
movements  of  the  head.  If  the  former,  the  eye  is  hj-peropic;  if  the 
latter,  myopic.  Inasmuch  as  the  image  of  the  vessels  in  low  degrees  of 
myopia  would  be  formed  onh'  at  a  considerable  distance  from  the  ob- 
served eye  (30  to  120  cm.),  and  since  no  sharp  image  would  be  obtained 
m  either  emmetropia  or  low  degrees  of  hyperopia  farther  away  than 
30  cm.,  any  considerable  degree  of  ametropia  may  be  excluded  by  failure 
to  obtain  a  direct  image  except  at  a  long  range  or  a  very  short  distance 
from  the  patient's  eye. 

Before  attempting  a  quantitative  estimation  of  refraction  by  means 
of  the  ophthalmoscope,  certain  fundamental  rules  must  be  observed: 

1.  Both  surgeon  and  patient  must  have  relaxed  accommodation. 

2.  A  certain  definite  spot  in  the  ej-e-ground  upon  which  to  focus 
should  be  selected. 

3.  The  observer  should  approach  as  close  as  possible  to  the  eye 
under  observation. 

4.  In  order  to  ascertain  correctly  the  refraction  error,  the  observer 
must  be  emmetropic,  or,  if  not,  render  this  eye  enmietropic  by  using  the 
proper  correcting  lens,  in  the  form  either  of  spectacles  or  of  an  equiva- 
lent glass  placed  behind  the  sight-hole  of  the  ophthalmoscope. 

The  emmetropic  observer  can  see  the  details  of  the  myopic  eye- 
ground  only  dimly  without  the  aid  of  a  correcting  glass,  and  not  at  all 
if  the  myopia  is  of  high  degree.  By  placing  concave  glasses  beiiind  the 
sight-hole  of  the  ophthalmoscope  the  convergent  rays  which  leave  the 
observed  eye  are  rendered  less  and  less  convergent,  until  that  glass  is 
reached  which  just  yields  a  distinct  image — /.  e.,  one  which  has  ren- 
dered the  convergent  rays  parallel. 

The  emmetropic  observer  can  see  the  details  of  a  hyperopic  eye- 
grountl  distinctly  without  the  aid  of  a  correcting  glass,  unless  the  hyper- 
opia is  of  very  high  degree,  by  anellbrt  of  accommodation  which  renders 
his  crystalline  lens  more  convex,  anil  thus  causes  the  divergent  rays 
whicli  leave  a  hyperopic  eye  to  ix'come  parallel.  But,  with  acconuno- 
dation  relaxed,  he  sees  distinctly  the  details  of  the  fundus  through  a 
convex  lens  placed  behind  the  ophthalmoscope;  this  slu)uld  be  substi- 
tuted for  other  stronger  convex  lenses  imtil  the  strongest  one  is  reached 
with  which  a  clear  image  is  still  i)ossible — /'.  e.,  one  which  has  rendered 
the  divcigcnt  rays  parallel,  while  tlie  next  highest  number  creates  a 
blur  over  the  details  of  the  eye-ground. 

From  what  has  been  said  it  follows  tliat  the  strongest  convex  len>, 
placed  in  position  in  the  ophtiialmoscope,  with  which  the  enmietropic 
observer  can  still  see  the  details  of  the  funchis  at  the  point  selected 
measiires  the  degree  of  hyperojiia;  the  weakest  concave  lens, 
of    myopia,      'i'lie    hypeidpia    usually    is    somewhat    iMcater,    .*ind    the 


DETERMINATION  OF  REFRACTION  BY  THE  OPHTHALMOSCOPE        113 

myopia  somewhat  less,  than  the  result  obtained  by  ophthalmoscopic 
examination. 

In  order  to  estimate  the  refraction  of  the  eye  examined,  the  hyper- 
opic  observer  must  subtract  from  the  convex,  or  add  to  the  concave, 
lens,  which  yields  him  a  sharp  image  of  the  fundus,  the  amount  of  his 
own  error,  while  the  myopic  observer  must  add  to  the  convex,  or 
subtract  from  the  concave,  lens,  with  which  he  sees  the  eye-ground  the 
degree  of  his  own  near-sightedness. 

In  order  to  calculate  the  amount  of  lengthening  or  shortening  of  the 
eye  equal  to  a  lens  which  neutralizes  the  myopia  or  hyperopia  in  any 
given  case,  and  provided  the  distance  between  the  surgeon's  eye  and 
that  of  the  patient  is  not  more  than  2.5  cm.,  the  following  table,  which 
was  prepared  by  the  late  Mr.  Nettleship,  is  useful : 

Hyperopia  of    1  D  represents  a  shortening  of 0.3    mm. 

2D  "  "  0.5      " 

3D  "  "  1 

oD  "  "  1.5      " 

6D  "  "  .......  2 

9D  "  "  3 

12  D  "  "  4 

18  D  "  "  6 

Myopia  of         ID  represents  a  lengthening  of 0.3     " 

2D  "  "  0.5      " 


3D 
5D 
6D 
9D 
12  D 
18  D 


0.9 

1.3 

1.75 

2.6 

3.5 

5 


By  this  table  the  depth  of  an  excavation  in  the  papilla  may  be 
measured.  For  instance,  if  the  bottom  of  the  pit  required  —  5D  for 
its  sharp  examination,  and  the  margin  of  the  nerve  was  seen  without 
any  glass,  the  depth  of  the  excavation  would  be  1.3  mm. 

The  presence  of  astigtJiatism  may  be  ascertained  by  means  of  the 
ophthalmoscope  and  the  upright  image  because  all  points  of  the  portion 
of  the  fundus  under  examination  are  not  in  focus  at  the  same  time — 
e.  g.,  the  retinal  vessels  running  in  the  directions  which  correspond  to 
the  principal  meridians. 

Thus,  when  two  vessels  cross  each  other  at  right  angles,  the  vertical 
branch  may  be  sharply  seen,  while  the  horizontal  one  presents  a  blurred 
image,  or  the  upper  and  lower  margins  of  the  disk  may  be  clear,  but  the 
lateral  borders  indistinct.  The  amount  of  hyperopia  or  myopia  of 
the  vertical  meridian  is  equal  to  the  strongest  convex,  or  weakest  con- 
cave, glass  which  makes  distinct  the  vessels  running  in  a  horizontal 
direction.  The  refraction  of  the  horizontal  meridian  is  determined  by 
the  glass  which  yields  a  clear  image  of  the  vessels  running  in  a  vertical 
direction.  As  the  vessels  do  not  correspond  to  the  layer  of  the  rods 
and  cones,  the  measurement  is  an  approximation. 


114 


OPHTHALMOSCOPY    AND    SKIASCOPY 


Compound  astigmad.sni  is  deterniined  by  fiiuling.  in  hyperopia,  the 
strongest  convex  lens  which  the  vessels  in  each  meridian  will  bear  with 
the  preservation  of  a  distinct  ima^e,  and  subtracting  the  one  from  the 
other,  thus  finding  the  difference  between  the  meridians — i.  e.,  the 
amount  of  astigmatism.  In  liigh  degrees  of  astigmatism  the  optic 
disk  usually  appears  as  an  ellipse,  its  long  axis  corresponding  with  the 
meridian  of  greatest  refraction. 

The  measurement  of  astigma- 
tism in  this  manner,  with  any 
degree  of  accuracy,  requires  much 
practice,  a  perfect  control  of  the 
accommodation,  and  even  then 
must  never  be  employed  to  the 
exclusion  of  other  and  more  trust- 
worthy methods. 

2.  The  Indirect  Method 
(Method  of  the  Inverted  Image). 
The  patient  and  surgeon  are 
seated  in  the  same  relative  po- 
sitions as  have  already  been 
described  in  connecton  with  the 
direct  method,  and,  if  the  right 
ej'e  is  to  be  examined,  the  ophthal- 
moscope is  held  in  the  right  hand 
at  a  distance  of  30  cm.  from  the 
patient,  who  is  instructed  to  look 
at  the  right  ear  of  the  examiner.  A 
convex  lens  of  20  D,  held  between 
the  surgeon's  left  thumb  and  iiulex- 
finger,  while  the  remaining  lingers 
are  rested  uj^on  the  ])row  to  steady  the  hand,  is  placcnl  at  about  its  own 
focal  lengtii  in  front  of  the  patient's  eye,  directly  in  the  path  of  the 
rays  returning  from  the  fundus,  which  are  thus  brought  to  a  focus  and 
form  an  aerial  image  between  the  observer  and  the  glass. 

If  the  left  eye  is  to  be  examined,  the  ophthalmoscope  is  held  in  the 
left  hand,  and  the  jxitient  instructed  to  look  at  the  surgeon's  left  car. 
wliile  th(!  lens,  grasped  in  the  fingers  of  the  right  ham!  in  the  mannei 
just  described,  is  placed  in  position. 

The  image  which  is  found  at  a  certain  distance  in  front  of  the  object 
glass  may  not  jjresent  itself  to  the  observer  as  a  distinct  picture,  owinf 
to  his  inability  to  acconunodate  for  the  point  of  its  forniati(»n.  Thii 
accommodative  strain  may  be  relieved  and  the  image  nuignilied  b}- 
placing  behind  i  he  opiithalmoscope  a  convex  glass  of  5  D,  which  adapt 
the  enunetropic  ()l)s('iver,  with  relaxed  accommodation,  for  a  point  2' 
cm.  distant.  If  t  he  observer  is  presbyopic,  or  has  a  d(>ficient  amplitud 
of  accommodation,  this  additional  lens  is  absolutely  necessary;  while 
he  is  hyperopic,  the  degree  of  his  liyperopia  should  lie  added  to  th 
gla»ss  used  as  a  magnifier.     The  observer  po.ssessing  a  luoder.-ite  degre 


Fiii.  5G.- — Focusing  of  the  vessels  by  the 
meridians  of  an  astigmatic  eye;  the  parallel 
lines  on  each  vessel  represent  the  direction 
of  the  meridians  throUKh  which  a  distinct 
image  of  the  vessel  is  obtained. 


OrHTHALMODIAPHANOSCOPY  115 

of  myopia  requires  no  lens  in  the  ophthalmoscope,  because  he  views  the 
aerial  image  at  his  far  point,  while  if  his  myopia  is  of  high  grade,  he 
will  need  a  weak  concave  glass. 

With  the  indirect  method  of  examination  the  field  is  larger  than  in 
the  direct  method.  Although  individual  objects  in  the  field  are  small 
and  sharply  defined,  the  details  of  the  fundus  are  less  perfectly  revealed 
than  with  the  direct  method.  In  young  subjects  in  the  macular  region 
a  bright  reflex  encircles  an  elliptic  dark  area  containing  in  its  center  a 
reddish  or,  less  frequently,  a  bright  point  surrounded  by  a  small  brilliant 
ring.     These  characteristics  are  not  always  present. 

A  qualitative  estimation  of  the  refraction  with  the  indirect  method 
may  be  ascertained  with  the  mirror  alone,  in  the  manner  already 
described  (see  page  114).     Furthermore,  ametropia  of  high  degree  may 


Fig.   57. — Method  of  an  indirect  examination  with  the  opthalmoscope. 

be  recognized  by  varying  distance  of  the  object-lens  from  the  eye. 
Withdrawal  of  the  lens  from  the  eye  causes  the  image  to  appear 
smaller  in  hyperopia,  larger  in  myopia. 

The  measurement  of  the  degree  or  quantity  of  the  refraction  and 
the  estimation  of  astigmatism  by  the  indirect  method  were  at  one 
time  much  practised,  but  in  practical  work  the  methods  are  so  far 
inferior  to  those  usually  employed  (skiascopy,  ophthalmometry)  that 
their  description  is  omitted. 

Ophthalmodiaphanoscopy.  —  With  the  ophthalmodiaphano- 
scope, designed  by  Carl  Hertzell,  it  is  possible  to  make  examinations  of 
all  parts  of  the  eyeball  and  of  the  orbit  around  and  posterior  to  the 
globe.  Dr.  H.  F.  Hansell  thus  describes  the  instrument:  It  consists 
of  an  80-candlepower  electric  lamp,  strengthened  by  a  reflector,  which 
increases  the  power  of  the  light  to  100  candlepower.  The  lamp  is 
held  by  the  patient  far  back  in  his  mouth  and  a  black  mask  is  adjusted 
to  protect  the  face.  The  anterior  rays  pass  through  the  buccal  plate 
of  the  superior  maxillary  bone,  through  the  antrum  and  its  roof  to 


116  OPHTHALMOSCOPY    AND    SKIASCOPY 

the  floor  of  the  orbit;  the  posterior  rays  pass  through  tho  hard  and 
soft  palate,  the  lateral  walls  of  the  nose,  the  anterior  cells  of  the 
sphenoid,  and  pass  to  the  median  orbital  walls.  The  eye-ground  is 
illuminated  from  behind,  below,  and  from  the  median  side.  The 
observer  approaches  the  lighted  pupil  as  near  as  po<:sible  and  examines 
the  illuminated  fundus  without  the  aid  of  any  other  instrument.  If 
the  eyes  are  ametropia  (myopic)  a  correcting  glass  should  be  worn, 
and  Hansell  finds  mydriasis  advantageous.  According  to  Hertzell, 
the  optic  nerve  appears  more  opaque  than  it  does  in  ordinary  ophthal- 
moscopic examination,  its  outlines  are  sharply  defined,  and  if  a 
pigment  ring  exists,  it  is  distinct.  The  retinal  veins  are  very  dark, 
the  arteries  somewhat  lighter  in  color;  the  macula  appears  as  a  dark 
spot.  Retinal  hemorrhages  appear  as  dark,  sharply  defined  areas. 
A  tumor  would  diminish  the  illumination  and  obscure  the  fundus 
details.  The  brilliant  transillumination  of  the  sinuses  and  orbit  is 
instantly  obstructed  b}'  the  presence  of  a  growth,  thickening,  or 
opacity,  and  the  diagnosis  thereby  facilitated.  The  author's  experi- 
ence with  the  instrument  is  limited  to  a  few  observations  made  witii 
Dr.  Hansell;  it  seems  to  be  of  distinct  value  in  the  diagno.sis  of  orbital 
and  sinus  disease. 

Ophthalmometry. — This  term  indicates  mensuration  of  the  eye, 
and,  as  usually  employed,  is  limited  in  its  application  to  the  measure- 
ment of  the  ra(hus  of  curvature  of  the  cornea  (kcratomdnj).  In  order 
to  practice  ophthalmometry,  instruments  for  taking  the  measurement 
of  the  radius  of  curvature  of  the  cornea  have  been  constructed,  and 
are  known  as  ophthalmometers.  The  ophthalmometer  most  in  use  is 
the  one  devised  by  Javal  and  Schiotz. 

Other  instruments  are  those  designed  l)y  Leroy  and  Dubois,  Reid, 
Hardy,  Chambers-Inskeep,  and  Sutcliffe.  In  the  opinion  of  the 
author,  a  suitable  ophthalmometer,  or,  more  accurately,  keratometer, 
is  of  the  greatest  service  in  determining  the  refraction  of  the  cornea 
and  the  cUrection  of  its  principal  mcMidians.  None  of  these  instru- 
ments should  be  used  to  the  exclusion  of  other  methods,  esi>ecially 
the  employment  of  mydriatics  and  skiascopy.  (P'or  a  full  description 
of  the  method  of  using  the  ophthalmometer  see  Appendix,  page  7G3). 

Optometry  is  a  term  which  indicates  th(^  principles  involved  in  the 
measurement  of  the  refi'action  (jf  an  (\ve  by  its  limits  of  distinct  vision. 
The  instrument  which  thus  scM-ves  to  (let(Mniin(>  the  rdraction  of  the 
eye  is  called  an  optometer. 

Optometers  are  based  upon  ;i  iiuhiIht  of  piiuciplcs.  I'or  instaru'c, 
a  single  convex  lens  by  which  the  diiection  of  tiie  luminous  rays 
emanating  from  an  object  is  ciianged,  and  consecjuently  the  determi- 
nation of  the  icfraction  of  the  exc  icudcred  jiossible,  constitutes  an 
ojjtometcr.  Other  optonieleis  nic  b.ased  upon  the  principle  of  a 
t<'lesc()i)e;  still  others  ui)om  the  nie.isurement  of  circles  of  dilTiision, 
upon  Scheiner's  experiment,  and  upttn  the  chrom.atic  aberration  of  the 
eye.  It  would  not  be  possible,  in  the  limits  of  this  manual,  to  describe 
in  detail   the   principles  involved  or  the  Aarious  forms  of  apparatus 


SKIASCOPY,    OR    THE    SHADOW-TEST    (rETINOSCOPY)  117 

which  have  been  employed.  Should  the  student  desire  to  pursue  the 
subject,  he  may  with  advantage  consult  the  chapter  devoted  to  this 
method  found  in  Landolt's  Refraction  and  Accommodation  of  the  Eye. 

Of  the  manj^  instruments  constructed  in  recent  times  for  the  pur- 
pose of  estimating  the  refraction  of  the  eye,  and  to  which  the  name 
refractometer  is  usually  applied,  the  best  is  the  one  devised  by  the  late 
Dr.  William  Thomson.^ 

Skiascopy,  or  the  Shadow=test  (Retinoscopy).- — This  is  a 
method  of  determining  the  refraction  of  the  eye  by  observing  the 
direction  in  which  the  light  appears  to  move  across  the  pupil,  when  it 
is  made  to  move  back  and  forth  across  the  face  by  rotation  of  the 
mirror  which  reflects  it  to  the  eye. 

With  the  ophthalmoscope,  as  has  already  been  explained,  the 
observer  may  look  into  a  myopic  eye  from  close  in  front  of  it  and  see 
an  erect  image  of  the  fundus,  w^hich  he  can  render  clear  by  the  proper 
concave  lens;  or,  in  the  same  eye.  from  a  greater  distance,  he  can  view 
an  inverted  image  of  the  fundus,  wnth  or  without  the  intervention  of  a 
convex  lens.  The  point  at  which  the  change  from  the  erect  to  the 
inverted  image  occurs  has  been  called  the  point  of  reversal.  It  is  the 
point  for  which  the  e3^e  is  focused,  and  is  the  far  point  of  distinct 
vision.  Skiascopy  is  simply  an  accurate  method  of  determining  this 
point  of  reversal. 


Fig.  58. — Skiascopy  with  the  plane  mirror. 

To  applj^  the  test  with  the  plane  mirror  the  surgeon  faces  the 
patient  at  a  distance  of  about  1  meter  or  less;  and,  holding  the  mirror 
to  his  own  eye,  reflects  on  the  patient's  face  the  light  from  a  lamp 
placed  near  the  mirror,  and  covered  with  an  opaque  shade  having  an 
aperture  3  to  6  mm.  in  diameter.  By  rotating  the  mirror  the  area  of 
light  it  throw^s  on  the  face  is  made  to  move  up  and  down,  or  from  side 
to  side,  or  obhquely.  The  part  of  the  Kght  that  falls  on  the  patient's 
pupil  is  condensed  on  his  retina,  forming  there  a  small  light  area 
which  also  moves  as  the  mirror  is  rotated;  for  the  plane  mirror  this 
retinal  hght  area  always  moves  in  the  same  direction  as,  or  "with," 
the  hght  on  the  face. 

In  Fig.  58  L  represents  the  lamp-flame,  screened  from  the  patient, 
and  A  and  B  two  positions  of  the  plane  mirror.  When  the  mirror  is  at 
A,  the  light  that  enters  the  eye  will  come  as  though  from  a  flame  at  /, 

'  Transactions  of  the  American  Ophthalmological  Society,  1902,  vol.  ix. 
^  This  section  lias  been  prepared  and  revised  by  Dr.  Edward  Jackson. 


118 


OPHTHALMOSCOPY  AND  .SKIASCOPY 


and  will  be  condonsod  toward  a,  on  the  lower  part  of  the  retina.  At 
this  time  the  hfj;ht  falls  on  the  lower  part  of  the  face.  But  when  the 
mirror  is  rotated  to  B,  the  light  entering;  the  eye  comes  from  the  direc- 
tion /',  and  is  condensed  toward  b,  on  the  upper  part  of  the  retina.  At 
the  same  time  the  light  on  the  face  moves  upward.  The  positions  of 
the  retina  in  hyperopia  emmetropia.  and  myopia  are  shown  at  H,  E, 
and  M.  It  will  be  noted  that  in  all  these  forms  of  ametropia  the 
movement  of  the  light  on  the  retina  is  with  the  light  on  the  face. 
When  skiascopy''  is  practised  with  a  concave  mirror,  the  lamp-flame 
which  serves  as  a  source  of  light  must  be  placed  behind  the  patient; 
and  the  light  area  on  the  retina  moves  in  an  opposite  direction 
"against"  the  light  on  the  face,  "against"  the  movement  of  the  mirror. 
In  Fig.  59  the  action  of  the  concave  mirror  is  represented.  When 
the  mirror  is  at  i4,  the  light  that  enters  the  eye  comes  from  the  focus 


Fig.  59. — Skiascopy  with  the  concave  mirror. 

of  the  mirror  at  I,  conjugate  to  the  position  of  the  lamp-flame,  and  is 
condensed  toward  a,  on  the  upper  part  of  the  retina;  and  when  the 
mirror  is  at  B  the  light  enters  from  V,  the  new  position  of  this  conjugate 
focus,  to  be  condensed  toward  b,  on  the  lower  part  of  the  retina — that 
is,  as  the  light  has  moved  upward  on  the  face,  it  has  moved  downward 
on  the  retina,  and  this  is  true  for  either  H,  E,  or  M. 

The  following  account  assumes  the  use  of  the  plane  mirror,  but  will 
apply  e(}ually  for  the  concave  mirror,  if  one  bears  in  mind  that  with  the 
latter  the  movement  in  the  pupil  is  always  in  the  opposite  direction, 
and  that  the  lens  before  the  patient's  eye  must  be  changed,  instead  of 
changing  the  surgeon's  distance  from  the  patient  (see  page  12;i). 

We  have  thus  seen  what  is  the  real  movement  t)f  the  light  on  the 
retina,  as  it  would  appear  in  the  back  of  an  enucleated  eye  with  the 
sclera  and  choroid  removed,  but  the  surgeon  does  not  see  it  in  that  way; 
he  can  only  watch  the  apparent  movement  as  seen  through  the  pupil. 
This  will  be  the  same  as  the  real  movement,  with  tlu>  light  on  the  face 
[plane  mirror]  when  he  sees  an  erect  image,  and  in  the  opposite  direc- 
tion when  he  sees  an  inverted  image. 

In  J-'ig.  (iO  M  represents  a  myopic  eyeball,  from  the  retina  of  which 
rays  come  out  and  are  focused  ;it  B,  the  ixn'nf  of  rtru:^(il.  Anywhere 
cIo.ser  to  the  eye  than  this,  as  at  .1,  an  erect  image  is  seen;  tlie  light 


SKIASCOPY,    OR    THE    SHADOW-TEST    (RETINOSCOPY)  119 

in  the  pupil  seems  to  move  with  the  hght  on  the  face.  Anywhere  be- 
yond the  point  of  reversal,  as  at  C,  an  inverted  image  will  be  seen,  and 
the  light  in  the  pupil  will  appear  to  move  against  the  light  on  the  face 
(see  page  118).  Just  at  the  point  of  reversal  B  it  is  impossible  to  see 
which  way  the  light  moves,  and  the  illumination  of  the  pupil  is  very 
feeble. 

At  one  or  two  diopters  from  the  point  of  reversal  the  light  is  com- 
paratively bright.  As  the  examiner  goes  farther  than  this  from  the 
point  of  reversal,  it  becomes  more  and  more  feeble.  With  the  same 
movement  of  the  mirror  the  apparent  movement  of  the  light  in  the 
pupil  is  quicker  as  the  point  of  reversal  is  approached.  These  varia- 
tions in  the  degree  of  illumination  and  rapidity  of  movement  may  aid 
the  expert  in  choosing  the  lens  to  be  next  placed  before  the  eye,  but  the 
thing  mainly  depended  on  is  the  direction  of  the  movement. 

Application  in  Myopia. — If  the  surgeon,  on  throwing  the  light  into 
the  eye,  finds  that  its  apparent  movement  in  the  pupil  is  against  the 


Fig.  60. — -Rays  coming  from  a  myopic  eyeball. 

hght  on  the  face,  he  must  be  farther  from  the  eye  than  the  point  of 
reversal  (B,  Fig.  60).  He  should  then  slowly  approach  the  patient, 
still  rotating  the  mirror  and  watching  the  apparent  movement  of  the 
hght,  until  he  finds  this  apparent  movement  is  with  the  light  on  the 
face,  as  at  A.  He  is  now  closer  to  the  patient  than  the  point  of  rever- 
sal, and  should  draw  back  and  observe  the  greatest  distance  (A)  at 
which  this  movement  with  the  light  on  the  face  can  be  distinguished; 
then,  drawing  farther  back,  he  observes  the  nearest  point  to  the  eye  (C) 
at  which  the  inverted  movement  can  be  seen,  and  the  point  B,  half-way 
between  A  and  C,  is  to  be  taken  as  the  point  of  reversal.  These  ob- 
servations should  be  repeated  until  the  exact  position  of  B  is  estab- 
lished. The  distance  from  B  to  the  eye  is  then  measured;  it  is  the  focal 
distance  of  the  glass  required  to  correct  the  myopia.  For  instance,  if  the 
erect  movement  is  seen  as  far  as  55  cm.  from  the  eye,  and  the  reversed 
movement  as  near  as  80  cm.,  the  point  of  reversal  will  be  about  67  cm., 
and  the  myopia,  therefore,  1.50  D. 

If  the  myopia  thus  discovered  is  high,  its  amount  can  be  most 
accurately  determined  bj'  putting  on  a  concave  lens  that  will  correct 
all  of  it  but  1  or  2  D,  measuring  what  is  left  b}-  skiascopy,  and  adding 
this  to  the  strength  of  the  lens  used  to  get  the  total  myopia. 

If,  on  the  other  hand,  the  myopia  is  very  low,  the  point  of  reversal 
may  be  at  so  great  a  distance  that  when  near  it  one  cannot  see  which 
way  the  hght  is  moving  in  the  pupil.     In  this  case  a  weak  convex  lens 


120 


OPHTHALMOSCOPY    AND    SKIASCOPY 


must  be  placed  before  the  eye,  the  point  of  reversal  found  witii  the  lens, 
and  then  the  strenfjth  of  the  lens  deducted  from  the  myopia  whicli  this 
indicates  in  oi'dci-  to  find  the  myopia  of  the  eye. 

Application  in  Hyperopia. —  Here  the  rays  from  the  retina  emerge 
divergent,  as  shown  by  the  broken  lines  in  Fig.  61,  and  there  can  be  no 
point  of  reversal  anywhere  in  front  of  the  eye.  The  surgeon  finds  the 
apparent  movement  of  tiie  light  in  the  pupil  is  with  the  light  on  the  face, 
and  it  continues  to  be  so,  no  matter  how  far  he  draws  back.  It  is  neces- 
sary, then,  to  place  a  convex  lens  (L)  before  the  eye  strong  enough  to 
render  the  rays  convergent,  and  so  to  make  a  point  of  reversal  a  con- 
venient distance  in  front  of  the  eye.  This  lens  does  two  things:  First, 
it  overcomes  the  divergence  of  the  rays;  this  takes  part  of  its  power. 
Second,  the  remainder  of  its  power  makes  the  rays  converge,  causing 
a  sort  of  artificial  myopia.  The  point  of  reversal  {B)  obtained  is  the 
point  of  reversal  for  this  artificial  myopia.  It  is  to  be  determined  as 
for  natural  myopia,  and  the  amount  of  myopia  it  represents  detlucted 
from  the  total  strength  of  the  lens.  The  remainder  will  be  the  power 
required  to  overcome  the  divergence  of  theraj's,or  the  strength  of  lens 
needed  to  correct  the  hyperopia. 


Fig.   ()1. —  Rays  eniorniiit;  from  ;i  liyporopic  eye. 


For  example,  suppose  the  movement  of  the  light  in  tlu>  pupil  is 
found  at  all  distances  to  be  uu'th  the  movement  of  the  light  on  the  face, 
and  on  placing  a  5  D  convex  lens  before  the  eye  it  is  founil  to  be  still 
with  the  movement  of  the  light  on  the  face  wiien  the  examiner  ap- 
proaches to  a  little  within  1  meter,  but  appears  reversed  if  looked  at 
from  a  distance  sligiitly  gicater  than  1  meter.  The  point  of  reversal 
then  is  at  1  meter;  1  I)  of  the  strength  of  the  lens  is  making  the  rays 
convergent,  while  the  other  4  1)  have  been  used  to  overcome  the  diver- 
gence of  the  rays  as  they  (^ame  from  the  eye.  Therefore  the  eye  must 
be  4  D  hyperopic.  Vov  accuracy  it  is  better  here,  as  in  the  case  of 
natural  my()i)ia,  to  make  (he  final  determination  with  a  liwis  that  brings 
the  point  of  reversal  '  •>  to  I  meter  from  the  eye. 

Application  in  Emmetropia.-  The  ajjplication  of  skiascopy  for  em- 
metroj)ia  is  preci.sely  the  same  as  for  hyperopia;  l)Ut  it  is  fouiul  that 
the  artificial  myopia  caused  by  the  con\'ex  lens  ('(pials  the  full  strengtl 
of  the  lens,  proving  that,  the  rays  must  lia\"e  emerged  from  the  eyi 
parallel. 

Application  in  Regular  Astigmatism, — The  priiu'ipl(>s  involved  an< 
the  methods  to  be  employed  are  essentially  the  same  as  in  myopia  o 


SKIASCOPY,    OR    THE    SHADOW-TEST    (rETINOSCOPY)  121 

hyperopia;  but  the  refraction  has  to  be  determined  in  the  two  principal 
meridians  instead  of  in  any  meridian  indifferently,  as  it  can  be  where 
all  meridians  are  alike.  To  determine  the  refraction  in  a  certain 
meridian  the  light  must  be  made  to  mos^e  back  and  forth  in  that  par- 
ticular meridian  by  rotating  the  mirror  about  an  axis  at  right  angles 
to  it. 

The  direction  of  either  of  these  principal  meridians  is  revealed  by 
the  area  of  light  in  the  pupil  assuming  the  form  of  a  more  or  less  dis- 
tinct hand  of  light,  extending  across  the  pupil  in  the  direction  of  this  me- 
ridian, when  its  point  of  reversal  is  approached.  This  band  can  be 
clearly  distinguished  only  when  the  surgeon's  eye  is  much  nearer  to  the 
point  of  reversal  for  one  principal  meridian,  than  to  the  point  of  rever- 
sal for  the  other  principal  meridian.  In  such  a  position  this  band  is, 
for  the  higher  degrees  of  astigmatism,  very  noticeable,  and  fixes  with 
the  greatest  accuracy  the  direction  of  the  principal  meridian.  When 
the  band-like  appearance  is  most  noticeable,  it  is  easy  to  cause  its  ap- 
parent movement  from  side  to  side;  but  it  is  more  difficult  to  distin- 
guish the  movement  in  the  direction  of  the  length  of  the  band.  Still, 
this  latter  movement  is  the  one  that  must  be  especially  watched,  and 
its  reversal  point  determined. 

When  the  astigmatism  is  very  low,  the  appearance  of  a  band  may  be 
very  indistinct,  or  not  at  all  perceptible.  But  in  such  cases  it  will  be 
found  that  when  the  surgeon  has  reached  the  point  of  reversal  for  move- 
ment of  the  light  in  one  direction,  there  is  still  distinct  movement, 
either  direct  or  inverted,  in  the  direction  at  right  angles  tot  his;  and  he 
will  thus  know  he  has  tested  one  meridian  of  an  astigmatism,  and  must 
in  the  same  way  ascertain  the  point  of  reversal  for  the  other  at  right 
angles  to  it.  When  the  surgeon  is  closer  to  the  eye  than  the  point  of 
reversal  for  either  meridian,  the  movement  will  be  with  the  light  on  the 
face  in  all  directions.  When  he  is  at  the  point  of  reversal  for  the  meri- 
dian which  has  its  point  the  nearer  to  the  eye,  there  will  he  no  distin- 
guishable movement  in  the  direction  of  the  hand  here  visible,  but  still  a 
movement  (with)  at  right  angles  to  it.  When  he  is  between  the  two  points 
of  reversal,  there  will,  in  the  direction  of  the  nearer  meridian,  be  an  in- 
verted movement  of  the  light  (movement  against),  but  in  the  other  meri- 
dian a  direct  movement  {movement  with).  When  the  farther  point  of 
reversal  is  reached,  the  direct  movement  in  its  meridian  ceases,  while  the 
movement  in  the  other  meridian  continues  inverted  (against).  When 
the  surgeon  has  drawn  back  beyond  both  points  of  reversal,  the  move- 
ment is  reversed,  against  the  light  on  the  face  in  all  directions. 

Having  determined  the  amount  of  myopia,  natural  or  artificial,  in 
both  principal  meridians,  the  strength  of  the  cylinder  required  to 
correct  the  astigmatism  will,  of  course,  be  the  difference  between  the 
refraction  for  the  two  meridians.  Having  thus  ascertained  it,  it  is  well 
to  put  this  cylinder  before  the  eye  and  to  see  if  it  does  accurately  correct 
the  astigmatism,  giving  the  same  point  of  reversal  for  all  meridians  of 
the  cornea;  and,  for  accuracy,  the  spheric  lens  which  will  bring  this 
point  of  reversal  to  the  distance  of  }itol  meter  should  be  used  with  it. 


122  OPHTHALMOSCOPY    AND    SKIASCOPY 

Application  in  Irregular  Astigmatism. — If  the  pupil  is  dilated,  it 
will  always  !)(;  found  that  the  refraction  of  the  eye  varies  in  different 
parts  of  it,  so  that  points  of  reversal  for  different  parts  of  the  pupil  lie 
at  different  distances  in  front  of  the  eye;  and  at  the  point  of  reversiil 
and  near  it,  both  direct  and  reversed  movements  of  the  light  are  visible 
at  the  same  time  in  these  different  parts  of  the  pupil.  Usually  there  is 
at  the  center  of  the  pupil  a  considerable  area  tluit  has  about  the  same 
point  of  reversal,  called  the  visual  zone.  This  is  the  part  through  which 
light  will  come  to  be  focused  on  the  retina  when  the  eye  is  in  use.  For 
practical  purposes  it  is  to  the  refraction  of  the  visual  zone  that  atten- 
tion should  be  paid,  the  refraction  in  the  other  parts  of  the  pupil  being 
of  little  practical  importance.  On  account  of  the  small  size  of  the 
visual  zone  in  many  eyes  it  is  best  to  applj''  skiascopy  from  a  distance 
of  less  than  1  meter  from  the  patient's  e\'e. 

When  the  visual  zone  of  the  pupil  differs  materially  in  refraction 
from  the  part  of  the  pupil  that  surrounds  it,  the  eye  is  said  to  present 
aberration.  This  is  called  positive  when  the  center  of  the  pupil  is  more 
hyperopic  or  less  myopic,  and  negative  when  the  opposite  is  the  case. 
When  the  aberration  is  high,  on  examining  it  from  near  the  point  of 
reversal  of  the  margin  of  the  pupil,  the  movement  of  the  light  will  be 
swift  at  the  margin  and  slow  in  the  center,  making  it  look  as  if  the  light 
in  the  pupil  were  wheeling  around  a  fixed  point  at  the  center.  This 
appearance  is  marked  in  conical  cornea.  Aberration  of  moderate  de- 
gree causes  the  appearance  of  a  ring  of  light  at  the  margin  of  the  pupil, 
which  has  a  very  distinct  movement  when  the  point  of  reversal  for  the 
center  of  the  pupil  has  been  reacluMl. 

Measurement  of  Accommodation  by  Skiascopy. — The  near 
point  of  acconmiodation  can  be  determined  by  having  the  patient  fix 
the  upper  edge  of  the  plane  mirror,  or  the  forehead  just  above  it,  and 
approaching  his  eye  until  the  movement  of  light  and  shadow  in  his 
pupil  is  clearly  with  that  of  the  mirror,  in  spite  of  his  strongest  effort 
to  accommodate  for  the  distance  of  the  mirror.  The  point  at  which 
this  direct  movement  cannot  be  overcome  by  acconnnotlation  is  the 
near  -point. 

This  can  be  tested  before  any  measurement  of  the  ri'fraction  has 
been  made,  or  after  the  refraction  has  been  determined  and  the  cor- 
recting lenses  placed  before  the  eyes.  In  the  latter  case  the  distance 
of  the  near  point  from  the  eye  will  be  the  focal  distance  of  the  lens 
e(|ualling  the  acconunodalion.  If  tlie  light  in  tiie  pupil  itegins  to 
move  with  the  light  on  the  face  at  one-third  meter,  although  a  strong 
effort  of  accommodation  is  made,  as  shown  hy  the  convergence  of  the 
visual  axes,  the  total  accommodation  is  3  1). 

Letters  may  be  placed  on  the  upper  part  of  the  mirror  pla(i\  or  on  a 
special  card,  to  give  the  patient  a  definite  object  to  iixate.  Such  an 
object  may  be  placed  nearer  to  the  jxitient  or  faither  away  than  the 
observer's  eye.  If  the  two  eyes  are  found  lo  dilTcr  in  acconunoda- 
tive  power  the  difference  can  be  eciualized  by  lenses  |)laced  in  front  of 
them.     The  len.ses  reijuired  to  neutralize  the  movenu'nt  of  light  and 


CYCLOPLEGICS    AND    MYDRIATICS  123 

shade  in  the  pupil  when  the  patient's  gaze  is  fixed  at  a  distance,  as  at 
one  meter,  measure  the  relative  accommodatio?i  for  that  amount  of 
convergence.  This  method  of  testing  the  eyes  has  been  elaborated 
by  Cross,  Sheard  and  others  into  a  method  which  is  called  ^'Dynamic 
Skiametry." 

The  Concave  Mirror. — With  the  concave  mirror  the  movement 
in  the  pupil  is  reversed  (see  page  118);  and  one  cannot  vary  much  the 
distance  of  the  mirror  from  the  patient's  eye,  but  must  keep  a  fixed 
distance  (usually  somewhat  less  than  1  meter),  and  bring  the  reversal 
to  this  point  by  changing  the  lenses  used  before  the  eye. 

Cycloplegics  and  Mydriatics.^ — In  addition  to  the  use  of  the 
mydriatics  in  the  treatment  of  diseases  of  the  eye — e.g.,  iritis — these 
drugs  are  employed  as  aids  in  an  accurate  determination  of  ametropia. 
With  the  ophthalmometer  and  by  obtaining  the  manifest  correction 
good  results  may  be  obtained;  but  in  all  patients  of  suitable  age,  and 
in  the  absence  of  contra-indicating  symptoms,  an  active  mydriatic 
should  be  employed  in  the  measurement  of  all  errors  of  refraction. 
The  mydriatic  (cycloplegic)  accomplishes  three  purposes: 

1.  It  dilates  the  pupil,  and  permits  a  thorough  exploration  of  the 
interior  of  the  eye,  as  well  as  a  more  perfect  examination  of  the  lens  and 
vitreous  humor  than  could  be  obtained  without  its  aid.  The  student 
should  not,  of  course,  think  it  necessary  to  dilate  the  pupil  of  each 
eye  which  he  subjects  to  an  ophthalmoscopic  examination;  but  glasses 
should  not  be  adjusted  without  a  thorough  knowledge  on  the  part  of 
the  examiner  of  all  the  details  of  the  eye-ground  and  the  transparent 
media. 

2.  It  paralyzes  the  action  of  the  ciliary  muscle  and  places  the  accom- 
modation in  abeyance,  rendering  manifest  types  of  ametropia  which 
otherwise  would  remain  latent. 

3.  It  fulfils  the  important  function  of  giving,  if  its  action  is  pro- 
longed, as  for  example  with  atropin,  physiologic  rest  to  the  eye  that 
is  under  its  influence,  and  consequently  helps  to  subdue  any  retino- 
choroidal  disturbance  or  other  congestive  condition  that  pre-existing 
eye-strain  may  have  originated. 

In  practice,  various  mydriatic  (cj^cloplegic)  drugs  are  employed,  the 
most  common  being  the  sulphates  of  atropin,  hyoscyamin,  and  duboi- 
sin,  and  the  hydrobromate  of  homatropin  and  scopolamin. 

(a)  Atropin. — Atropin  sulphate  is  usually  employed  in  a  strength 
of  4  grains  (0.26  gm.)  to  the  ounce  (30  c.c).  A  drop  of  such  a  solution 
dilates  the  pupil  in  about  fifteen  minutes,  and  a  very  few  moments 
later  begins  to  paralj^ze  the  accommodation,  which  sustains  a  full 
paralysis  in  about  two  hours.  The  effect  of  atropin  upon  the  accom- 
r^'  Imodation  remains  for  a  week,  but  if,  as  is  commonly  the  case,  the  drug 
til  hs  used  for  several  days  at  a  time,  this  influence  is  much  prolonged,  and 
;■,)  ttull  return  to  the  previous  powers  of  accommodation  is  not  secured  for 
vv-    about  twelve  or  fourteen  days. 

!S'  '  The  terms  "cycloplegic"  and  "mydriatic"  are  constantly  used  syiionymously, 

•  a    although  some  of  the  mydriatics  have  little  or  no  influence  on  the  ciliary  muscle. 


124  OPHTHALMOSCOPY    AND    SKIASCOPY 


In  using,  atropin  sulphate  for  the  purpose  of  correcting  errors  of 
refraction,  a  sohition  of  the  strength  fj;iven  above  should  be  instilled 
into  the  eye,  one  drop  at  a  time,  three  times  for  at  least  a  day,  prepara 
tory  to  the  determination,  and  in  young  subjects  possessing  hyperopic 
eyes,  with  active  ciliary  muscles,  especially  if  there  is  associated  spasm 
of  accommodation,  the  drug  must  be  continued  for  several  days,  or 
even  longer,  before  the  desired  result  is  reached. 

(6)  Hyoscyamin  is  usually  employed  in  the  strength  of  2  grains 
(0.13  gm.)  to  the  ounce  (30  c.c.).,  in  the  same  manner.  It  produces 
wide  dilatation  of  the  pupil  and  complete  ciliary  paralj-sis,  the  effect 
of  which  lasts  from  six  to  seven  days.  Many  surgeons  prefer  this 
drug  to  atropin,  and  believe  that  its  effects  are  equall}'  good,  while 
it  enjoys  the  advantage  of  a  much  more  temporary  action  upon  the 
function  of  the  ciliary  muscle.  The  salt  must  be  neutral,  and  the 
solution  filtered  through  neutral  paper  (Rislcy). 

(c)  Hyoscin  and  duboisin  in  similar  strength  have  similar  actions, 
the  latter  drug  being  even  more  transitory  than  hyoscj'amin  in  its 
effect,  return  to  accommodative  power  occurring  in  from  four  to  five 
days.  Both  of  them  have  the  disadvantage  of  producing  marked 
constitutional  disturbances,  at  times  rendering  their  employment 
disadvantageous.  Hyoscin  is  chemically  and  physiologically  identical 
with  scopolamin. 

(d)  Homatropin  is  a  drug  which  produces  a  transitory  effect  upon 
the  ciliary  muscle,  full  return  of  accommodation  usually  occurring  in 
about  fifty  hours  after  the  last  instillation. 

To  use  this  drug  properly  it  must  be  employed  by  cumulative  in- 
stillations in  the  strength  of  8  to  16  grains  (0.52-1.04  gm.)  to  the  ounce 
(30  c.c),  one  drop  of  such  solution  being  used  every  fifteen  minutes  for 
an  hour  and  a  half  preceding  the  deterniiiiation,  and  thou  waiting  forty 
minutes.  At  the  end  of  this  time  the  maximum  effect  of  the  ilrug 
upon  the  accommodation  is  secured.  In  the  opinion  of  some  surgeons 
this  drug  is  an  insufficient  paralyzer  of  accommodation,  but  if  caution 
in  regard  to  th(^  cumulative  instillations  is  observed,  and  the  rule  given 
above  carefully  followed,  (Mitirely  satisfactory  results  may  l)e  obtained. 
Its  influence  may  be  neutralized  i)y  eserin.  Some  surgeons  prefer 
homatropin  in  gelatin  disk  form,  associated  with  cocain,  in  the  deter- 
mination of  errors  of  refraction.  The  author  has  never  been  able  to 
convince  himself  of  their  superiority  to  a  solution  of  the  drug,  and 
regards  the  addition  of  cocain  to  the  solution  as  ailistinct  disadvantage. 

(e)  Scopolamin,  introduced  by  Raehlmann,  may  be  employcil  in  the 
strength  of  2  grains  (0.13  gm.)  to  the  ounce  (30  c.c).  Two  instillations 
of  one  drop  each  forty-five  niinutes  apart  are  sufficient.  Mytlriasis 
begins  in  twelve,  and  is  (-oniplete  in  thirty  nuiutcs;  cvcloplegia  ocfurs 
in  about  forty-five  minutes.  Full  r(>turn  of  acconunoiiation  n>ay  be 
expected  in  from  five  to  six  days.  'I'oxic  syini)toins  staggering, 
vertigo,  drowsiness  and  dryiH-ss  of  the  throat  may  dt^velop  in 
susccptihlc  subjects  atid  tlic  author  has  ab.-itidoiicd  its  use  as  a 
cycloplcgic. 


J 


CYCLOPLEGICS   AND    MYDRIATICS  125 

It  is  not  safe  to  use  strong  mydriatics  in  elderly  persons,  and  they 
must  never  be  employed  if  there  is  any  symptom  of  glaucoma.  They 
are  usually  unnecessary  when  that  age  has  been  reached  after  which  the 
accommodation  is  so  weakened  that  hyperopia  ceases  to  be  latent,  and 
they  are  rarely  employed  after  the  forty-fifth  year;  but  Hess  and  Duane 
have  demonstrated  that  hyperopia  may  be  as  latent  at  the  age  of  forty- 
five  or  fifty  as  it  is  in  young  persons,  and,  therefore,  the  need  of  a 
mydriatic  may  be  equally  important. 

Euphthalmin  is  an  active  mydriatic  in  a  5  to  10  per  cent,  solution. 
It  produces  maximum  dilatation  of  the  pupil  in  about  fifteen  or  twenty 
minutes,  and  the  pupil  returns  to  its  normal  size  in  five  to  six  hours. 
Its  influence  on  accommodation  is  so  slight  that  it  has  no  practical 
value  as  a  cycloplegic.  It  is  an  admirable  agent  for  producing  brief 
dilatation  of  the  pupil,  and,  fortunately,  it  has  no  perceptible  effect 
upon  the  cornea.  It  may  be  combined  with  cocain,  1  per  cent,  of 
each,  and  its  mydriatic  efficiency  thereby  enhanced. 

Hydrochlorid  of  cocain,  in  addition  to  its  anesthetic  action,  is,  in  2 
to  4  per  cent,  solution,  an  excellent  mydriatic,  but  its  effect  upon  the 
accommodation  is  so  slight  that  it  is  valueless  for  the  purpose  of  prepar- 
ing an  eye  for  the  estimation  of  any  error  of  refraction. 

Other  mydriatic  drugs  which  may  be  mentioned  are  eyhedrin  homat- 
ropin,  1  :  10  (Groenouw);  mydrol,  10  per  cent.;  methylatropin,  5  per 
cent.,  and  atroscin.  The  last-named  drug  is  similar  to  scopolamin  in 
its  action. 


CHAPTER  IV 
NORMAL  AND  ABNORMAL  REFRACTION 

The  cornea,  aqueous  humor,  crystalline  lens,  and  vitreous  body 
are  the  media  by  which  rays  of  light  passing  into  the  eye  are  refracted 
and  brought  to  a  focus  with  the  production  of  an  image  on  the  retina. 
Because  the  two  surfaces  of  the  cornea  are  practically  parallel  and  the 
index  of  refraction  of  the  cornea  and  the  aqueous  humor  are  the  same, 
the  dioptric  apparatus  may  be  reduced  to  the  anterior  surface  of  the 
cornea  and  the  anterior  and  posterior  surfaces  of  the  crystalline  lens. 
The  cornea  is  the  principal  lens  when  the  eye  is  at  rest,  and  it  has  a 
higher  refractive  power  than  the  crj-stalline  lens;  but  during  maximum 
accommodative  effort  the  refractive  power  of  the  crystalline  lens  ap- 
proaches that  of  the  cornea.  The  formation  of  a  distinct  retinal 
image  requires  that  the  curvature  of  the  corneal  meridians  shall  he 
symmetric,  that  the  plane  of  the  lens  shall  be  perpendicular  to  the 
visual  line,  that  its  sectors  shall  have  a  uniform  density  in  corresponding 
layers,  and  that  the  focal  length  of  the  dioptric  apparatus  shall  cor- 
respond with  the  length  of  the  visual  axis. 

Emmetropia. — To  the  normal  eye,  which  produces  a  distinct 
image  of  distant  objects  on  the  retina,  without  accommodative  effort, 
the  term  emmetropic  is  applied,  and  the  condition  may  be  defined  as 
follows : 

Emmetropia  is  that  refractive  condition  of  the  eye  in  ichich  the  visual 
axis  corresponds  exactly  u'ith  the  focal  length  of  the  dioptric  apparatus 
when  at  rest;  the  far  point  lies  at  infinity,  and  the  eye,  in  its  condition  of 
minimum  refraction,  is  adapted  to  facets  parallel  rays  on  the  retina.  The 
principal  focus  lies  on  the  retina. 

The  ('inni(>tropic  eye  has  an  average  length  of  about  22  nun., 
although  emmetropia  is  still  possible  with  a  longer  or  shorter  axis,  if  the 
curvature  of  the  ocular  lenses  varies  in  proportion.  Emmetropia, 
although  it  exists  but  rarely,  is  the  ideal  state  of  refraction.  Such  an 
eye  has  a  range  of  vission  from  infinity  to  its  near  point  (see  table,  page 
39).  Glasses  are  not  nuiuired  for  distant  vision,  neither  are  tiicy 
needed  for  reading  or  close  work  until  that  age  is  reached  when  tiie 
accommodative  power  begins  to  decline — i.  e.,  about  the  fortj'-tifth 
year.  No  great  departure  from  emmetropia  can  long  exist  witiuiut 
producing  more  or  less  disturbMiicc  of  the  function  of  vision  and  of  the 
nutrition  of  the  ocular  tissues,  or  without  originating  somi*  of  the 
numerous  general  and  reflex  symptoms  which  aris(>  from  "(\ve-strain." 
To  restore  the  eye,  the  refraction  of  which  is  abnormal,  to  a  coiulition 
of  emmetropia,  or  at  least  one  approaching  it,  constitutes  a  most 
impoitani  pari  of  llic  pr.'icficc  of  ophtli;diuoIog\'.  This  will  be  more 
readily  concecjed  when  it  is  icnieiiil>eic(l  thai  eniinet  lopia  is  conip:ira- 


J 


AMETROPIA  127 

tively  uncommon,  occurring  in  not  more  than  1.5  to  2  per  cent,  of 
properly  examined  eyes.  Some  statistics,  those  of  Tenner,  for 
example  (quoted  by  Duane)  record  4  per  cent,  of  emmetropia 
among  4800  school  children. 

Ametropia.^ — To  the  eye  which  fails  in  the  requirements  just  de- 
scribed the  term  ametropia  is  applied,  and  the  condition  may  be  defined 
as  follows: 

Ametropia  is  any  departure  from  the  normal  optical  condition — that  is, 
from  an  exact  correspondence  between  the  visual  axis  and  the  focal  length 
of  the  dioptric  apparatus  when  at  rest.  The  principal  focus  is  not  a 
point  or  does  not  lie  on  the  retina. 

Ametropia  is  denominated  axial  when  the  length  of  the  eyeball  is 
increased  or  diminished,  and  curvature  when,  the  axis  remaining  un- 
changed, the  curvature  of  lenses  of  the  eye  undergoes  variations. 
Ametropia  presents  itself  under  three  conditions:  (1)  Hypermetropia, 
hyperopia,  far-sightedness,  or  oversightedness;  (2)  myopia,  short-sighted- 
ness, or  near-sightedness;  (3)  astigmatism  or  astigmia. 

It  is  convenient  to  distinguish  the  first  two  classes  of  ametropia  by 
the  relative  position  of  the  principal  focus  to  the  retina. 

Hyperopia  is  that  form  of  ametropia  in  which  the  retina  is  situated  in 
front  of  the  principal  focus  of  the  eye.  The  visual  axis  of  the  eye  is  shorter 
than  the  focal  length  of  the  dioptric  apparatus  when  at  rest. 

The  far  point  of  the  eye  is  negative,  and  is  represented  by  the 
point  behind  the  eye  to  which  rays  must  converge  before  entering  the 
eye,  in  order  to  be  united  on  the  retina.  The  refractive  apparatus  of 
the  hyperopic  eye,  in  a  condition  of  minimum  refraction,  is  adapted  to 
bring  rays  converging  to  this  point  to  a  focus  on  its  retina.  Rays 
passing  out  of  a  hyperopic  eye  have  a  divergence  as  if  they  came  from 
this  point. 

Causes  and  Varieties. — The  eyeball  may  be  abnormally  short,  con- 
stituting axial  hyperopia;  a  deficiency  of  1  mm.  in  the  length  of  the 
optic  axis  produces  3  diopters  of  hyperopia;  or  its  refractive  power  maj'- 
be  deficient,  curvature  hyperopia;  an  increase  of  1  mm.  in  the  length  of 
the  radius  of  curvature  of  the  cornea  produces  a  hyperopia  of  6  diop- 
ters; or  the  crystalline  lens  may  be  absent,  aphakial  hyperopia. 

Hyperopia  is  further  divided  into:  (1)  Manifest;  (2)  latent;  (3)  total. 
Manifest  hyperopia  (H.  m.)  is  represented  by  the  strongest  convex  lens 
through  which  an  eye  with  perfectly  intact  accommodative  power 
retains  distinct  distant  vision;  latent  hyperopia  (H.  1.)  is  the  amount 
infexcess  of  the  manifest  which  can  be  developed  by  the  use  of  a 
cycloplegic — for  example,  atropin;  total  hyperopia  (H.  t.)  is  the  sum 
of  the  manifest  and  the  latent — that  is,  the  entire  amount  of  the 
hyperopia  which  is  developed  after  paralysis  of  accommodation  or 
complete  relaxation  of  the  ciliary  muscle.  Evidently  latent  hyperopia 
is  the  difference  bocween  the  manifest  and  the  total.  Manifest 
hyperopia  is  either  facultative  or  absolute — ^facultative  when  it  can  be 
overcome  by  an  effort  ol  accommodation,  absolute  when  it  cannot  be 
overcome  by  an  effort  of  accommodation. 


128  NORMAL    AND    .\BNORMAL    REFRACTION 

Hypc'iopia  is  nearly  always  congenital,  and  is  often  hereditary, 
especially  its  hijjh  grades  In  some  senses  it  may  be  regarded  as 
due  to  an  imperfect  development  of  the  eyeball,  which,  however,  may 
increase  its  length  with  the  growth  of  the  rest  of  the  body,  and  this 
refractive  condition  may  diminish,  pass  into  emmet ropia,  or  its  approxi- 
mation, or  into  myopia.  An  apparent  increase  of  hyperopia  due  to 
failure  of  accommodation  caused  by  advancing  years  is  often  seen — 
that  is,  latent  hyperopia  becomes  manifest.  A  real  tendency  to  slow 
increase  of  hj'peropia  is  due  to  gradual  increase  of  the  size  of  the 
crystalline  lens.  In  early  life  none  of  the  existing  hyperopia  is  absolute 
unless  it  is  of  high  degree;  after  sixty-five  practically  all  of  it  becomes 
absolute.  Hyperopia  due  to  diminution  of  the  refractive  index  of 
the  lens  in  old  age  is  often  called  senile  hyperopia. 

Symptoms. — ^Hyperopia  renders  it  difficult  to  maintain  a  distinct 
image  of  small  objects — e.  g.,  printed  matter — for  prolonged  periods  of 
time.  If  the  effort  is  persisted  in,  the  accommodation  becomes 
exhausted,  aching  of  the  eyes  and  head — in  short,  the  result  of  eyc- 
strain — appears,  and  finally  the  work  must  he  discontinued  (accom- 
modative asthenopia).  Sudden  failure  of  accommodation,  with  con- 
sequent blurring  of  vision,  is  frequent,  and  often  first  appears  if  the 
patient  has  been  weakened  by  illness.  The  subjects  of  hyperopia  not 
uncommonly  place  a  book  or  small  objects  in  a  strong  light  in  order  to 
contract  their  pupils  and  thus  render  vision  clearer. 

Hj'peropia  frequently  gives  rise  to  spasm  of  the  accommodation, 
owing  to  the  persistent  contraction  of  the  ciliary  muscle  necessary  to 
overcome  this  error  of  refraction,  and  then  simulates  myopia,  distant 
vision  becoming  indistinct.  In  these  circumstances  concave  lenses 
may  improve  vision,  and,  in  ignorance  of  the  true  state  of  affairs,  are 
sometimes  prescribed,  much  to  the  detriment  of  the  patient.  A 
cycloplegic  will  reveal  the  real  condition  of  the  refraction.  It  occurs 
also  in  myopic  eyes,  which  api)ear  to  ho  more  myopic  than  th(\v  really 
are.  Spasm  is  prone  to  occur  in  individuals  of  neurasthenic  comlitiou, 
and  is  a  frequent  symptom  of  hysteria,  often  associated  with  cramp  of 
convergence;  it  bears  no  relation  to  the  vigor  of  the  accommodation, 
inasmuch  as  persons  with  relatively  feeble  acconunodation  may  have 
a  marked  cramp  of  the  ciliary  nuisde.  Therefore  spasm  of  accom- 
modation is  not  excess  of  accommodation  (see  page  41).  Spasm  of 
accommodation  is  not  confined  to  young  subjects,  but  may  t)ccur, 
and  in  stubborn  form,  after  the  fortieth  year  of  life.  It  may  be 
produced  in  noiinal  eyes  by  the  instillation  of  a  solution  of  an  active 
miotic. 

Insufliciciit  power  of  ;icconiiiio(l;ition,  /.  (..  stihnorniiil  accom- 
modation, may  give  rise  to  iiiMrUcd  Msth(Mio|)ia.  It  is  attr'il)Uted  by 
Theobald  to  a  congenital  insullieiency  of  the  ciliary  inuscl(>  (.^e(>  also 
page  41),  and  its  determination  and  correctio;>  in  refractive  work, 
is  most  important . 

Convergent  sfrahismus  is  often  I  he  earliest  syiiiploni  of  iiyperopia  in 
childhood;    it    arises    in    conneetion    with    elTorts    of    Mceommodation 


AMETROPIA  129 

(see  page  597).  When  the  hyperopia  is  too  great  to  be  managed 
by  the  accommodation,  the  affected  children  frequently  hold  their 
books  close  to  their  eyes,  and,  by  contracting  the  palpebral  fissures,  are 
enabled  to  see  better  than  with  the  book  at  a  greater  distance,  because 
the  object  is  seen  under  a  larger  visual  angle,  and  the  narrow  slit 
between  the  lids  cuts  off  the  more  divergent  rays.  These  children 
are  often  erroneously  supposed  to  be  near-sighted,  and  concave  glasses 
are  given  to  them,  which  increase,  instead  of  mitigating,  the  trouble. 

As  a  result  of  hyperopia  the  coats  of  the  eye  become  inflamed. 
Conjunctivitis,  blepharitis,  styes,  chalazia,  and  congestion  of  the  retina 
and  choroid  are  verj^  frequent  complications.  Persistent  headache, 
aggravated  by  using  the  eyes,  various  nervous  symptoms,  reflex  in 
their  nature,  as  well  as  disturbances  in  the  visual  function,  are  the 
common  results  of  hyperopia  (see  also  page  150). 

Determination  of  Hyperopia. — Hyperopia  always  exists:  If  dis- 
tant vision  is  not  made  worse  by  a  convex  glass;  if  the  patient  can 
read  fine  print  through  a  convex  glass  at  a  greater  distance  than  its 


Fig.  62. — Far  point  of  a  hyperopia  eye.  Rays  from  R  on  the  retina  of  the  hyperopic 
eye  after  refraction  diverge;  these  rays,  prolonged  backward,  would  unite  at  the  point 
R'.     R'  is  the  far  point. 

focal  length;  if  with  the  ophthalmoscope  the  interior  of  the  eye, 
otherwise  normal,  is  seen  distinctly  with  a  convex  lens;  usually  if  the 
near  point  hes  at  a  greater  distance  from  the  eye  than  is  proper  for  the 
age;  and  if  the  phenomena  described  in  connection  with  the  shadow- 
test  on  page  120  are  present.  To  ascertain  the  presence  of  latent 
hyperopia  a  C3^cloplegic  should  be  employed.  Its  use  is  imperative 
in  the  presence  of  spasm  of  accommodation.  The  ciliar}^  muscle  is 
fuUy  developed  in  hyperopic  eyes,  especially  the  circular  fibers,  which 
may  be  overdeveloped. 

Correction  of  Hyperopia. — The  principal  focus,  F,  of  the  hyperopic 
eye  Hes  behind  the  retina.  Consequently  the  retina,  R,  is  situated 
within  the  principal  focus,  and  its  conjugate  focus  or  far  point,  R' ,  is 
virtual  (Fig,  62).  Rays  from  R  seem,  after  refraction  by  the  eye,  to 
have  come  from  R';  conversely,  rays  converging  to  R',  after  refraction 
by  the  eye,  unite  in  R  on  the  retina.  The  rays  which  come  from  the 
retina,  R,  of  such  an  eye,  after  emerging  from  the  eye  are  divergent, 
and,  prolonged  backward,  would  unite  in  the  point  R' .  The  distance 
of  this  point  from  the  cornea  is  the  focal  length  of  the  glass  which 
corrects  the  hyperopia.     The  amount  of  divergence  of  the  emergent 

9 


130  NORMAL    AND    ABNORMAL    REFRACTION 

raj^s  is  dependent  on  the  degree  of  the  hyperopia — that  is.  the  dis- 
tance R  lies  in  front  of  F.  The  higher  the  degree  of  hyperopia  is,  the 
farther  R  Hes  in  front  of  F,  and  the  nearer  the  point  of  ihvergence  R' 
lies  to  R;  conversely,  the  lower  the  degree  of  hyperopia  is,  the  nearer 
the  point  R  lies  to  F,  and  the  farther  back  the  point  R'  hes.  The 
distance  of  R'  must  be  less  than  infinity;  otherwise,  the  eye  would  be 
emmetropic. 

If  parallel  rays  are  given  a  convergence  to  the  point  R'  by  a  convex 
lens  placed  before  the  eye,  the  rays  will  come  to  a  focus  at  the  point  R     , 
on  the  retina,  since  the  path  of  the  rays  passing  into  the  eye  after  refrac- 
tion by  a  convex  lens  (Fig.  63)  is  exacth'  the  same  as  that  of  the  rays    ' 
diverging  from  the  retina  and  passing  outward  (see  Fig.  62).  only  the    ; 
direction  is  reversed.     The  far  point,  R',  of  the  hyperopic  eye  is  the 
point  to  which  parallel  rays  must  be  given  a  convergence  by  a  convex 
lens  in  order  to  come  to  a  focus  on  the  retina.     The  amount  of  this   . 


Fig.  63. — Correction  of  hyperopia  by  a  convex  glass.  The  lens,  L.  Kives  to  parallel 
rays  a  converKcnce  toward  the  point  R';  they  will  consequently  he  united  on  the  retina, 
li-      R'  is  the  virtual  conjufiate  focus  of  R. 

necessary  convergence  represents  the  deficiency  between  the  refraction 
of  the  hyperopic  and  that  of  the  emmetropic  eye;  the  degree  of  hyper- 
opia is,  therefore,  in  an  inverse  ratio  to  the  distance  of  R'. 

To  correct  h3qieroj)ia  the  refraction  of  th(>  eye  must  be  increa.><e(i 
by  a  convex  lens  of  sufficient  strcMigth  to  bring  F  on  the  retina.  Thi:^ 
glass  corrects  the  hyperopia  by  shortening  the  focal  length  of  the  diop-i 
trie  apparatus  to  correspond  exactly  with  the  length  of  the  visual  axis. 
The  far  point  R'  is  removed  to  infiniiw  Parallel  rays  come  to  a  foou> 
on  the  retina  without  any  effort  of  acconinKHlation.  and  ra>s  emerging 
from  the  eye  are  i-endered  parallel. 

In  order  to  neutralize  the  hyperopia  that  convex  glass  must  b< 
selected  which  gives  tiie  greatest  visual  acuteness.  As  this  is  obtainct 
when  the  ictinal  image  is  sharply  formed,  and  as  this  occurs  when  ra\ 
are  brought  to  an  exact  focus  on  the  layer  of  rods  and  cones,  the  niaxi 
mum  sharpnc'^s  of  sight  is  the  most  satisfactory  evidence  that  rays  an 
exactly  focused  on  the  iclina.  If  these  rays  are  parallel,  the  gla* 
which  brings  theni  to  a  focus  on  llie  rc'tina  corrects  the  hyperopijj 
Rays  from  objects  at  6  meters'  (hsiance  are  sulliciently  par.alli'l  for  thi 
put  pose 

Correction  of  Hyperopia  with  Test-types  and  Trial-lenses.      Th 

card    of    test-letters,    in    good    ilhiniiiiat  ion      either    .artilici.al    hghl    < 


AMETROPIA  131 

ample  daylight — is  hung  on  a  wall,  at  4  to  6  meters  from  the  patient. 
A  pair  of  trial-frames  is  placed  before  the  patient's  eyes,  which  should 
be  under  the  influence  of  a  cycloplegic,  provided  he  is  not  beyond  the 
age  when  this  is  necessary,  and  one  eye  at  a  time  examined,  the  other 
being  screened  bj'  an  opaque  disk.  He  is  required  to  read  the  smallest 
letters  which  he  can  see  distinctly  on  the  card.  The  resulting  sharp- 
ness of  vision  is  noted.  A  convex  glass  is  next  placed  before  the  eye.  If 
this  glass  improves  vision,  but  does  not  raise  it  to  that  which  is  normal, 
stronger  lenses  are  tried  until  the  one  is  obtained  which  yields  the  maxi- 
mum visual  acuteness;  or,  if  the  stronger  glasses  do  not  improve  the 
vision,  successively  weaker  ones  are  tried  until  that  glass  is  found  which 
gives  the  greatest  sharpness  of  sight.  This  is  the  lens  which  corrects 
the  hyperopia.  Even  if  the  acuteness  of  vision  is  raised  to  that  which 
is  normal  b^'  a  convex  spheric  lens,  astigmatism  of  low  degree  is  not 
certainlj'  excluded  and  every  eye  should  be  examined  with  a  view  to 
discover  any  astigmatism.  If  none  exists,  the  convex  glass  is  all  that  is 
required  to  correct  the  ametropia. 

In  the  absence  of  a  mydriatic  and  the  presence  of  some  accommoda- 
tive spasm,  vision  being  equal  in  the  two  eyes,  a  more  suitable  glass  may 
often  be  obtained  b}'  testing  both  eyes  simultaneously,  because  with 
parallel  axes  the  accommodation  is  more  likely  to  undergo  relaxation. 
This  effect  may  be  further  increased  by  placing  a  prism  of  2°  or  3" 
(centrads)  before  one  eye,  with  its  base  inward.  The  effect  of  this  is 
to  relax  the  internal  recti  muscles,  and  indirectlj'  the  accommodation. 
It  is  a  good  plan  to  begin  bj^  placing  before  the  eyes  a  lens  of  stronger 
refraction  than  the  one  required,  and  gradualh'  weakening  it  by  con- 
cave glasses  of  successively  higher  numbers  until  normal  vision  is 
reached.     The  glass  required  is  the  difference  between  the  two. 

The  proof  that  the  glass  selected  is  the  correct  one  depends  upon 
the  ability  of  the  patient  to  focus  parallel  rays  on  the  retina.  Parallel 
rays  may  be  obtained  by  placing  an  object  at  the  principal  focal  dis- 
tance of  a  convex  lens.  The  principal  focal  distance  of  a  4  D  lens  is  25 
cm.  Therefore  if  the  glass  corrects  the  hyperopia,  the  patient  should 
be  able  to  read  fine  print  at  25  cm.  distance  with  -f  4  D  added  to  his 
correction.  If  he  reads  at  a  greater  distance  than  25  cm.,  some  hypero- 
pia is  still  uncorrected.  If  he  reads  at  a  shorter  distance  than  25  cm., 
the  hyperopia  is  probably  overcorrected. 

The  degree  of  hyperopia  vciay  also  be  determined  by  placing  a  con- 
vex lens  before  an  eye  the  accommodation  of  which  is  paralyzed,  and 
by  finding  the  distance  at  which  small  type  appears  most  distinct. 
Suppose  the  lens  selected  is  4  D  (focal  distance  =  25  cm.),  and  that  the 
patient  reads  best  at  33  cm.  Now  33  cm.  is  farther  than  the  principal 
focus,  and  the  rays,  therefore,  are  convergent  after  passing  through  the 
lens,  since  a  3  D  lens  would  render  them  parallel;  4  D  =  3  -|-  1  would 
give  them  a  convergence  of  1  D  to  the  conjugate  focus,  1  meter  back  of 
the  eye;  1  D,  therefore,  represents  the  amount  of  the  hyperopia  (see 
*page  132). 

Rule. — Subtract  from  the  lens  employed  the  lens  whose  focal  dis- 


132  NORMAL    AND    .\BNUKMAL    REFRACTION 

tance  equals  tho  distance  at  whicli  the  patient  reads.     The  difference  is 
the  dep;r('o  of  hyperopia. 

Correction  of  Hyperopia  with  the  Ophthahnoscope  and  Shadow- 
test. — To  t'oirt'ct  hyiKTopia  in  fluldren  before  they  are  old  enough  to 
read,  the  ophthalmoscope  and  skiascopy  are  the  means  upon  which 
reliance  is  placed,  but  these  methods  must  also  be  employed  in  adults. 
They  are  explained  on  paj?es  111  and  117. 

Ordering  of  Glasses. — After  the  degree  of  the  hyperopia  has  been 
determined,  the  very  important  question  presents  itself,  What  glass 
shall  be  ordered?  While  the  eye  is  under  the  influence  of  the  cyclople- 
gic,  distant  vision  is  distinct  with  the  full  correction;  after  the  effects 
of  the  drug  have  disappeared,  it  is  often  dim  with  the  full  correction, 
and  a  haze  seems  to  lie  over  all  distant  objects,  which  disappears  when 
the  glasses  are  removed.  On  the  other  hand,  the  headache,  asthenopia, 
and  congestive  troubles  return  if  the  hyperopia  remains  uncorrected. 
Spasm  of  accommodation  is  the  disturbing  factor  in  this  j)roblem,  and 
it  is  so  variable  in  different  individuals  that  no  precise  rule  can  lie  given. 
Many  persons  wear  a  full  correction  with  comfort,  and  do  not  need  any 
modification;  others  will  tolerate  only  a  small  part  of  the  full  correcting 
glass. 

There  are  two  methods  of  dealing  with  this  difficulty:  first,  to  order 
full  correction  while  the  eye  is  still  under  the  influence  of  the  mydriatic, 
and  to  insist  that  this  shall  be  worn  constantly  during  the  time  that 
the  accommodation  is  returning  to  its  normal  state.  If  distant  vision 
remains  dim,  after  full  acconnnodative  power  has  returned,  the  glasses 
may  be  weakened  sufficiently  to  secure  normal  sight  for  long  ranges. 

It  should  be  borne  in  mind  that  the  glass  which  gives  the  best  cor- 
rection at  4  to  6  meters  is  not  the  correcting  glass  for  the  total  H.  but, 
in  reality,  is  an  overcorrection  of  ^^  to  }q  D.  Strictly  speaking,  rays 
coming  from  these  distances  are  not  parallel,  ami  the  glass  which 
focuses  them  perfectly  on  the  retina  will  not  perfectly  focus  parallel 
rays.  Hence,  in  ordering  a  full  correction,  the  glass  which  gives  the 
best  vision  at  4  or  G  meters  must  be  weakened  by  I4  to  1^  D.  If  this 
fact  were  more  often  remembered,  less  difficulty  would  be  experienced 
in  inducing  jiatients  to  wear  a  full  correction. 

Second,  the  eyes  are  first  allowed  to  regain  their  full  power  of  ac-  ^ 
commodation  before  the  final  glass  is  prescribed,  and  this  is  the  jilan 
which  should  be  pursued.  If  vision  is  normal  with  th(>  full  strength  of 
the  glass,  it  may  be  ordered,  if  not,  it  should  b(>  reduced  to  that  miniber 
with  wiiich  full  visual  acuteness  is  obt:iine(l.  This  may  l)e  only  one- 
half,  one-fourth,  or  even  less,  of  the  full  .imount.  It  is  necessary  in 
th(!se  cases  to  increase  the  strength  of  the  glass  from  time  to  tinu*  as 
symptoms  of  fatigue  manifest  themselves.  When  the  glass  ordered  for 
distance  is  only  a  small  part  of  the  full  correction,  another  |>:iir  of  lenses 
for  lending  may  be  ordered  which  mibocHes  iie;trly  or  (|uite  the  full 
amount  of  correction. 

Afre(|uent  cause  of  inability  to  wenia  full  correction  de]>ends  upon 
the  development   of  convergi-nce  insufliciency,  causing  an  a.s.sociatec 


MYOPIA  133 

action  of  accommodation  with  the  muscular  effort  necessary  to  bring 
the  visual  axes  into  a  parallel  condition  (see  page  611). 

Other  methods  are  as  follows :  Instead  of  ordering  the  glass  nearest 
in  strength  to  the  full  correction,  with  which  the  patient  still  has  normal 
vision,  the  lens  which  neutralizes  the  total  hyperopia  may  be  reduced 
by  a  given  amount,  usuallj^  0.75  D.  Bonders  advised  a  glass  based 
upon  the  manifest  H,  to  which  one-quarter  of  the  latent  H  was  added. 
Macnamara  recommends,  in  absolute  h3'peropia,  the  use  of  a  convex 
glass,  the  strength  of  which  shall  be  equal  to  one-half  of  the  sum  of  the 
manifest  and  total  hyperopia — e.gr.,  manifest  H  =  1.5  D;  total  H  =  3.5  D 
H.  m.  4- H.  t.  =  5  D;  ordered -|- 2.5  D.  Evidently,  however,  it  is 
not  wise  to  formulate  a  fixed  rule.  The  amount  of  the  total  hyperopia 
which  should  be  corrected  depends  upon  many  factors.  The  author, 
if  convergence  is  ample,  usually  orders  the  full  correction  of  H  less 
0.25  D.  If  there  is  exophoria,  this  plan  must  be  modified,  or  the  defect 
remedied  by  prisms  or  by  prismatic  exercises.  The  indistinct  vision, 
caused  by  full  correction  of  H,  due  to  a  disturbance  of  the  relative  range 
of  accommodation  and  convergence,  may  be  overcome  by  systematic- 
ally training  the  convergence  (see  page  614).  Whether  a  glass  shall 
be  worn  constantly  or  not  depends  upon  the  symptoms  which  the  hy- 
peropia has  produced  and  the  character  of  the  patient's  work.  Fre- 
quently hyperopes  are  entirely  comfortable  if  reading-glasses  alone  are 
used.  Finally,  glasses  need  not  be  ordered  simply  because  hyperopia 
exists  especially  in  children;  but  only  when  it  gives  rise  to  the  symptoms 
which  have  been  described.  Thus,  one  person  may  easily  manage  one 
or  more  diopters  of  H  without  glasses;  another  may  have  all  manner  of 
asthenopic  and  reflex  nervous  symptoms  produced  by  1  D  of  H  or  even 
less.  Occasionally  very  high  degrees  of  h^^peropia  are  encountered 
12-14  D,  even  as  high  as  20  D  (J.  A.  Wilson)  and  sometimes  the 
reaction  to  these  high  grades  of  H 
is  not  conspicuous.  During  the 
war  a  number  of  examples  of  this 
character  came  under  the  author's 
observation  while  revising  the 
ocular  examinations  of  recruits 
and  in  some  instances  several 
members  of  the  same  family  were 
thus  affected.     The  vision  of  these     ^   f'^V ^^"A^^^^  ^^T  ^^j^^'P^^'opi^: 

1  .   ,    1  .  O-A,  1  he  optic  axis;  iv,  the  nodal  point  of 

nigh  hyperopes  m  no  case  reached  lens;  V-M,  the  visual  line,  cuts  the  cornea 

the  normal  standard  even  with  the  at   inner  side  of  optic  axis;  0-N-V,  the 

best  correcting  glass.  ^he^macX°'^'  '"^  *^'^  ""^^^  ''  positive;  M. 

The  visual  line  is  often  very 
much  displaced  to  the  inner  side  of  the  cornea  in  hyperopia,  causing  a 
very  large  value  of  the  angle  gamma. 

Myopia  is  that  form  of  ametropia  in  which  the  retina  is  situated 
behind  the  principal  focus  of  the  eye,  and  only  those  rays  which  diverge 
from  some  point  nearer  than  infinity  can  come  to  a  focus  on  the  retina. 
This  point  is  the  far  point  of  the  myopic  eye. 


134 


NORMAL  AND  ABNORMAL  REFRACTION 


The  far  point,  therefore,  is  hinited  by  the  amount  of  divergence 
necessary  to  bring  the  focus  of  the  rays  on  the  retina.  The  higher  the 
degree  of  myopia  is,  the  closer  will  the  far  point  r  he  to  the  ej'e.  Rays 
coming  from  the  retina  converge  to  the  far  point  and  form  there  an 
image  (Fig.  65).  This  image  can  be  seen  by  the  ophthalmoscope. 
The  far  point  and  the  retina  are  conjugate  foci  (see  page  119). 

Cause  and  Varieties. — -Myopia  may  be  produced  by  increased 
refraction  of  the  cornea  or  crystalline  lens,  curvature  myopia,  or  by  too 
great  a  length  of  the  optic  axis,  axial  myopia.  In  the  majority  of  cases 
myopia  is  due  to  elongation  of  the  optic  axis,  often  the  result  of  patho- 
logic changes  in  the  coats  of  the  eye. 


Fig.  65. — Far  point,  of  a  myopic  eye.  Rays  diverging  from  the  retina,  c,  will,  after 
refraction,  converge  to  r;  conversely,  rays  diverging  from  r  will,  after  refraction,  con- 
verge to  c;  r  is  the  far  point;  r  and  c  are  also  conjugate  foci. 


Myopia  may  also  be  occasioned  by  changes  in  the  shape  of  the 
cornea  as  a  result  of  disease — for  example,  conical  cornea  in  which 
case  there  is  also  high  astigmatism,  or,  as  a  transitory  condition 
(see  also  page  328)  in  iritis  and  iridocyclitis.  Coi'tical  opacities  are 
a  frequent  cause  of  myopia.  According  to  Frenkel,  bilateral  opacities 
usually  produce  bilateral  myopia,  while  unilateral  opacities  more  fre- 
quently give  rise  to  unilateral  myopia,  which  may  affect  either  eye, 
according  as  the  one  or  other  eye  is  most  used  for  near  vision.  The 
myopia  thus  caused  appears  to  be  an  axial  and  not  a  curvature  myo- 
pia. Myopia,  unlike  hyperopia,  is  rarely  congenital.  It  usually 
makes  its  appearance  from  the  eighth  to  the  tenth  year,  especially 
during  the  early  school  years,  hence  the  term  "<Sc/ioo/  ?nyopia,"  and 
it  tends  to  be  progressive.  Sometimes  it  is  the  continuation  of  a  proc- 
ess started  in  hyjx'ropic  eyes,  especially  in  tlu).>^t'  with  astigmatism, 
and  the  gradual  transition  from  hyperojiia  to  myopia  is  not  infre- 
quently seen  among  patients  who  return  for  examination.  Accord- 
ing to  Risley,  there  may  be  an  ancsl  of  the  increase  of  myopia  as 
the  result  of  treatment  and  the  optical  correction  of  ametropia. 

Myopia  is  njore  j)revalent  in  some  countries  than  in  otluTs,  and  is 
especially  fre(iU(>nt  in  (.5erniany.  in  the  higher  classes  of  the  schools, 
reaching,  according  to  Cohn,  (iO  per  cent.  iSIyopiu  is  said  to  be  more 
common  among  Jews  than  among  Christians  of  the  same  social  class 
(Sydney  Sicphenson).  Sattler,  however,  is  unc(»nvinced  that  there 
really  exists  a  racial  inclination  to  myopia.     Harman's  statistics  indi- 


MYOPIA  135 

cate  that  most  of  the  cases  of  myopia  in  early  childhood  occur  in  boys, 
but  the  highest  degrees  appear  in  girls.  Although  the  largest  number 
of  myopes  is  found  among  the  upper  classes, — that  is,  among  those 
upon  whom  the  demands  of  modern  civilization  fall  most  heavily,  and 
among  artisans  whose  work  requires  close  inspection, — high  grades  of 
this  refractive  defect  may  also  be  found  among  those  who  apparently 
do  not  use  their  eyes  for  close  work,  and  occasionally  among  ilHterates 
and  among  children  who  have  not  j'et  been  subjected  to  the  influence 
of  school  life.  It  may  be  that  it  will  be  found  that  these  subjects  of 
myopia  have  been  reared  under  conditions  in  which  they  have  been 
obliged  to  devote  themselves  assiduously  to  work  at  very  near  range 
(Sattler).  It  has  been  suggested  that  the  high  degrees  of  mj-opia  not 
uncommonly  encountered  among  Bedouins  and  Egyptians  may  be 
due  to  the  frequency  of  corneal  opacities  among  them  (Duane). 

^lyopia  is  frequently  hereditarj-,  and  may  occur  in  several  members 
of  one  family.  Harman  found  hereditary  transmission  in  9  per  cent,  of 
the  cases  he  investigated.  It  has  been  stated  that  the  transmission 
is  more  frequent  to  daughters  than  to  sons.  With  a  strong  predisposition 
to  myopia  the  elongation  of  the  eyeball  may  take  place  under  com- 
paratively unimportant  exertion.  Although  myopia  usuall}'  begins  in 
childhood,  there  ma}'  be  a  late  development  of  this  refractive  error,  that 
is,  it  may  occur  after  the  twentieth  j^ear  of  life.  This  late  development 
of  mj'opia  has  been  observed  in  association  with  constitutional  dis- 
turbances, with  malaria  (T.  Becker),  with  goiter  and  obesity  (R. 
Wirtz) ,  and  with  pituitary  body  struma. 

That  acute  posterior  scleroticochoroiditis  may  occasion  myopia, 
especially  posterior  staphj-loma,  as  originall}^  taught  by  von  Graefe,  is 
not  admitted  by  Sattler,  that  is,  that  it  is  the  cause  of  the  myopia. 
Obvious  choroiditic  changes,  according  to  him,  are  to  be  considered  as 
a  complication  which  etiologically  has  nothing  to  do  with  the  progres- 
sion of  the  m\'opia;  although  he  admits  that  choroiditis  may  give  rise  to 
a  rapid  increase  and  pernicious  course  in  m^^opia.  The  author  has  pub- 
lished some  observations  which  indicate  that,  as  the  result  of  severe 
choroiditis,  myopia  may  rapidly  develop  in  certain  cases,  observations 
which  are  in  accord  with  the  statements  of  Knies,  Priestley  Smith,  and 
others.  Occasionalh'  after  an  acute  illness,  especially  one  of  the  ex- 
anthemata, a  myopia  develops,  or  there  maj-  be  a  sudden  increase  in  a 
pre-existing  myopia.  Increase  in  the  densitj^  of  the  lens  as  the  result 
of  beginning  cataract  may  cause  myopia  (index  myopia) ,  the  so-called 
second  sight  (see  page  429),  and,  according  to  Hirschberg,  the  late 
development  of  myopia — that  is,  after  the  fortieth  year,  unassociated 
with  cataract  formation — is  not  an  uncommon  sign  of  diabetes.  Tran- 
sitory increase  of  hyperopia  has  also  been  observed  in  diabetes,  due  to 
changes  in  the  lens  (Lundsgaard) . 

In  normal  eyes  the  sclera  does  not, yield  to  the  intra-ocular  pressure, 
but  if  from  am^  cause  its  resisting  power  is  reduced,  distention  takes 
place  and  the  anteroposterior  axis  of  the  eyeball  is  elongated.  Among 
the  causes  which  have  been  invoked  to  explain  the  elongation  of  this 


136  NORMAL    AND    ABNORMAL   REFRACTION 

axis  of  the  eye — i.  e.,  the  production  of  myopia — are  the  following: 
The  incentive  given  by  the  shape  and  size  of  the  orbit  to  greater  de- 
velopment of  the  eyeball;  the  compression  of  the  eyel)all  by  the  exterior 
muscles,  causing  distention  of  its  coats  l)ack\vard  on  account  of  the 
excessive  convergence  rendered  necessarj'  by  the  close  range  at  which 
myopes  are  obliged  to  work;'  the  strain  of  accommodation;  racial 
peculiarities;  inflammatory  changes  within  the  eye — for  example, 
scleroticochoroiditis,  inducetl  by  habits  of  life  which  promote  fulness  of 
the  veins  of  the  head  and  neck  and  hinder  the  egress  of  the  blood  from 
the  eye  or  are  set  up  by  eye-strain  itself  induced  by  excessive  study,  bad 
ocular  hygiene,  imperfect  illumination,  etc.;  and  an  inherited  tendency 
and  a  nutritive  defect  in  the  sclera,  the  connnencement  and  increase  of 
the  myopia  being  caused  by  general  and  local  vascular  congestion, 
which  are  the  result  of  constitutional  tlisturbance — for  example, 
cardiovascular  and  nasal  disease  (Batten);  increased  intra-ocular  ten- 
sion and  distention  of  the  eyeball  posteriorly  due  to  obstruction  to 
the  outflow  of  lymph  from  the  lymph  spaces  between  the  retina  and 
choroid  into  the  lymph  spaces  of  the  optic  nerve  (Edridge  Green); 
retardation  of  the  outflow  from  the  eye  due  to  congenital  deficiency 
of  the  ciliarj^  muscle  which  causes  increased  intra-ocular  pressure 
and  expansion  of  the  eve  which  is  distensible  during  earlv  life  (A. 
Wood). 

Prolonged  use  of  the  eyes  at  near  work  necessitating  excessive 
convergence  and  muscle  pressure  has  been  invoked  to  explain  the 
acquisition  of  myopia  in  many  cases,  but  only  a  portion  of  those 
subjected  to  such  a  strain  become  myopic.  Indeed,  there  is  sufficient 
clinical  evidence  to  show  that  over-use  of  the  eyes  anil  excessive  ac- 
commodation or  convergence  are  not  the  main  factors  in  the  develop- 
ment of  myopia.  Therefore,  as  Fuchs  remarks,  special  ailditional 
factors  must  l^e  present:  predisposition,  improjier  ocular  and  general 
hygiene,  spasm  of  accommodation,  and,  especially,  astigmatism.  Ir- 
regular, inverse,  and  oblicjue  astigmatism  are  of  marked  significance 
in  this  respect.  In  the  study  of  myopia,  a  ilisturbed  balance  of 
nutritive  factors  must  be  given  due  consideration. 

Among  other  causes  of  less  moment  may  be  mentioned  an  unusually 
great  distance  between  the  j)upils,  rendering  convergence  more  ditlicult. 
a  divergent  scjuint,  and  a  large  size  of  the  angle  gannna  (in  this  cas« 
negative),  demanding  more  strain  on  the  part  of  the  eye  muscles  in  tlu 
efforts  of  convergence.  After  myopia  is  once  proiluced  the  eyeball.  h\ 
its  oval  shape  and  greater  size,  may  act  as  a  cause  of  the  furthc 
development  of  this  icfraetive  defect  i)y  reason  of  the  increased  muscu 
lar  efToit  wliieli  is  re(|uired  to  rotiite  such  a  globe  inward  during  con 

*  ('ompreesion  of  the  eyeball  in  tlicse  circunistimces  may  be  causotl  by  tlu-  ex 
tortml  rectus.  .\oc()r(liiiK  to  Stilling  tlic  suiicrior  oblique  is  the  principal  coiupreft 
\i\H  muscle  ill  iii}'o|)ia,  tlic  low  |n>sitioii  of  the  trochlea  iiiercasiiin  (lie  iiiiiount  < 
force  which  thiH  imiscle  exercises  on  thi-  ^lobc.  Schiiiiilt-I{iiiipler  rejecteil  St illiiiR 
coiiclusioiis,  and  llaiiibci^er's  iiicasurcmeiits  do  not  ctuifirin  Stillinn's  contcntio 
that  in  myopia  the  vertical  diameter  of  the  orbit  is  decreased. 


MYOPIA  137 

vergence,  and  the  compressing  effect  of  the  external  recti  muscles  on 
the  increased  posterior  segment  of  the  eyeball. 

At  first  probably  all  cases  of  myopia  are  progressive,  but  many  are 
checked  because  the  eyes  are  removed  from  the  strain  of  close  work  or 
are  placed  under  better  hygienic  surroundings;  that  is,  the  myopia  be- 
comes stationary.  Other  cases  may  progress  until  the  increased  effort 
of  convergence  demanded  by  the  increased  myopia  becomes  too  diffi- 
cult to  sustain,  one  eye  deviates  outward  and  there  is  produced  a 
divergent  strabismus.  Then  further  increase  of  myopia  may  stop,  or 
the  inflammatory  changes  already  set  up  within  the  eye  may  continue, 
the  distention  of  the  ocular  coats  increases,  and  the  most  serious  or- 
ganic lesions  arise;  in  other  words,  there  is  malignant  or  pernicious 
myopia. 

Symptoms. — The  symptoms  of  myopia  naturally  arrange  themselves 
into  two  classes,  subjective  and  objective. 

The  subjective  symptoms  are  those  which  arise  because  the  range  of 
vision  is  limited  by  a  radius  of  a  few  centimeters.  Distant  objects  are 
not  clearly  perceived  by  the  myopic  patient,  because  as  soon  as  an  ob- 
ject passes  beyond  his  far  point  it  becomes  indistinct.  According  to 
Seggel,  the  light-sense  diminishes  with  an  increase  of  myopia.  Percival 
Haj^  finds  that  if  refractive  errors  are  low,  they  do  not  affect  the  light- 
sense,  but  if  they  are  high  they  tend  to  increase  the  light  difference. 

Many  myopes  have  an  inclination  to  avoid  outdoor  sports  on 
account  of  their  poor  vision,  and  exhibit  a  greater  fondness  for  occu- 
pations which  come  within  their  range — e.  g.,  reading,  drawing,  etc. — 
than  for  others  which  require  good  distant  vision.  The  prolonged  con- 
gestion of  the  eyes  which  such  habits  entail  tends  to  increase  the  my- 
opia. Headache  and  reflex  phenomena  are  unusual  accompaniments 
of  myopia  unless  complicated  with  astigmatism,  which  is  an  important 
factor  in  the  further  increase  of  the  refraction.  Myopia,  however, 
frequently  causes  aching  of  the  eyeballs,  very  imperfect  ocular  endur- 
ance, congestion  of  the  conjunctiva — indeed,  many  of  the  symptoms 
which  are  strictly  asthenopic,  especially  when  the  choroid  is  under- 
going the  changes  which  are  determining  the  increase  in  the  refractive 
power.  That  the  full  enjoyment  of  outdoor  sports  is  not  at  all  incom- 
patible with  the  existence  of  myopia  properly  corrected  is  well  known, 
and  it  is  an  interesting  fact,  pointed  out  by  Goldberg,  that  many  ex- 
cellent marksmen  are  mj^opic. 

The  objective  symptoms  of  high  myopia  may  embrace:  (1)  A  notably 
prominent  and  elongated  eyeball,  with  a  large  and  somewhat  sluggish 
pupil;  (2)  a  rather  stupid  expression  of  the  countenance  from  inability 
to  note  the  expression  in  the  face  of  others;  (3)  a  peculiar  manner  of 
reading — the  book  is  held  stationary  and  the  face  is  moved  from  side 
to  side,  following  each  line;  (4)  certain  characteristic  ophthalmoscopic 
appearances.  With  the  direct  method  the  optic  disk  appears  enlarged ; 
at  its  outer  side  there  often  is  a  crescentic  area  of  whitish  hue,  depend- 
ing upon  alterations  in  the  choroid,  known  as  a  conus  or  myopic  crescent. 
This  area  may  begin  next  to  the  disk  with  a  space  of  complete  atrophy, 


138  NORMAL    AM)    .\BX<)HMAL    liKFRACTION 

succeeded  bj'  a  rim  of  partial  atrophy  and  pijiniont  disturbance,  which 
in  its  turn  merges  into  a  patch  of  choroidal  congestion  {posterior 
staphyloma).  Sometimes  the  entire  disk  is  surrounded  by  areas  of 
choroidal  disturbance,  and  the  general  choroid  may  exhibit  many 
alterations  depending  on  congestion,  edema,  rarefaction,  atrophy,  and 
pigment  accumulation  (see  also  page  139  and  Fig.  66).  Weiss  and  B. 
Alex.  Randall  have  described  a  curvi-linear  reflex,  generally  at  the 
nasal  side  of  the  disk,  as  a  prodromal  sign  of  myopia.  (5)  Divergent 
squint.  The  squinting  eye  is  often  amblj-opic.  Binocular  vision 
does  not  exist  in  such  a  case;  the  better  eye,  freed  from  the  necessity 
of  convergence,  reads  at  the  far  point  without  any  effort,  and  glasses  for 
reading  are  sometimes  unsatisfactory  because  the  print  appears  smaller 
on  account  of  its  removal  to  a  distance  greater  than  the  far  point  of 
the  eye. 


Fig.  66. — Eye-Kround  in  pronressivc  myopia.  Large  posterior  staphyloma  sur- 
rounding the  nerve-head.  Macular  region  occupied  by  areas  of  semi-atrophio  retino- 
choroidal  lesions. 

The  visual  axis  in  nu'opia  sometimes  passes  through  the  cornea  at 
the  outer  side  of  the  optic  axis;  the  aiujlc  (jamma  is  then  najativc,  and  the 
eye  in  looking  at  a  distant  object  turns  inward  in  order  to  bring  the 
visual  line  to  fix  on  it,  giving  rise  to  an  apparent  convergent  squint 
(Fig.  67).     This  renders  necessary  a  greater  degree  of  convergence. 

Myopic  eyes  are  popularly  considered  as  strong  ej'es  because  they 
see  fine  print  at  close  ranges.  This  is  true  only  in  tho.^^e  ca.><es  in  which 
the  tunics  of  the  eye  have  sufferetl  no  injury — where,  for  example,  the 
myopia  is  of  moderate  degree  and  the  eye-grounds  are  normal. 

Myopia  does  not  usually  decrease  with  age.  but.  on  th(^  contrary, 
tends  to  increa.se  U|)  to  adult  life  or  later. 

Very  high  (10  I)  and  higher)  degrees  of  myopia  (nitilitindiil  or  pir- 
niciouH  myopia)  are  often  marked  by  ravages  in  the  structure  of  the 


MYOPIA  139 

choroid  and  retina.  The  pigment-cells  wander  off  in  some  places  and 
accumulate  in  others,  producing  marked  contrasts  in  the  appearance 
of  the  eye-ground.  Large  areas  of  atrophy,  ghstening  white  in  color, 
alternate  with  black  splotches,  and  at  times  hemorrhages  occur.  The 
macular  region  is  especially  prone  to  degenerative,  atrophic,  and  hem- 
orrhagic changes.  According  to  Hirschberg,  these  central  changes, 
characteristic  of  high  myopia,  are  due  to  mechanical  stretching  and  not 
to  inflammatory  processes.  The  disk  is  often  surrounded  by  an 
atrophic  area,  the  posterior  staphyloma,  which  represents  an  area  of 
thinned  and  distended  sclera. 

Posterior  staphyloma  should  not  be  confused  with  the  conus  or 
myopic  crescent,  and,  according  to  Schnabel,  who  accepts  von  Jaeger's 
view,  it  should  be  regarded  as  an  anomaly  in  the  form  of  the  eye — that 


Fig.   67. — Angle  gamma  in  myopia  which  ;s  negative. 

is,  a  malformation  and  not  the  result  of  disease.  He  believes  that 
there  is  a  connection  between  retinochoroiditis  and  posterior  staphy- 
loma, but  that  "the  primarily  emmeti'opic  or  hyperopic  eye  will  not 
become  affected  with  retinochoroiditis  of  the  macula  in  consequence 
of  acquired  myopia;  only  eyes  with  posterior  staphyloma  resulting 
from  congenital  malformation  have,  in  addition  to  excessive  myopia,  an 
especial  predisposition  to  that  grave  disorder."^  The  vitreous  humor 
is  semifluid,  and  floating  opacities  are  often  visible,  sometimes  being  so 
large  as  to  obscure  vision.  Owing  to  the  intimate  relation  between 
retinal  nutrition  and  the  pigmented  epithelium  of  the  retina,  the  loss 
of  the  latter  is  followed  by  diminution  in  the  visual  acuteness.  In 
high  grades  of  myopia — 15  to  20  D,  and  sometimes  still  higher — 
the  condition  of  the  eye  is  desperate,  and  the  morbid  processes  may 
culminate  in  detachment  of  the  retina  and  complete  blindness.  Oc- 
casionally, in  the  macular  region  of  myopic  eyes  may  be  seen  an 
intensely  black  area,  about  the  size  of  the  nerve-head,  with  a  slightly 
grayish  center,  and  surrounded  by  a  lighter  ring.  It  stands  out  well 
defined.  This  is  the  so-called  black  spot  of  the  macula  in  myopia,  first 
described  by  Forster  and  later  by  Fuchs.  It  is  interpreted  in  the  visual 
field  by  a  scotoma.  The  prognosis  is  unfavorable  and  the  disease  may 
be  progressive,  although,  according  to  some  observers,  this  lesion  renders 
the  eye  less  liable  to  the  other  complications  of  myopia.  Butler  and 
Stargardt  have  described  a  central  green  spot  in  myopia. 

^" Relationship  of  Staphyloma  Posticum  to  Myopia,"^!.  Schnabel,  System  of 
Diseases  of  the  Eye,  edited  by  Norris  and  Oliver,  vol.  iii. 


140 


NORMAL  AND  ABNORMAL  REFRACTION 


Not  only  is  corneal  astigmatism  a  potent  factor  in  the  increase  of 
myopia,  but,  according  to  Senn,  it  bears  an  important  relation  to 
central  choroiditis  and  destructive  change  in  the  fundus. 

In  myopia  the  ciliary  body  appears  to  be  flat,  and  the  transverse 
diameter  of  the  ciliary  muscle  is  smaller  than  it  is  in  the  normal  eye, 
because  its  circular  fibers,  comparatively  little  employed  in  the  act  of 


.jx..^|vj^ 


^ 


Fig.  68. — Ciliary  body  of  a  myopic  eye 
(specimen  prepared  by  Dr.  C.  M.  Hos- 
mer).  Notice  the  abnormally  flat  ap- 
pearance ot  the  ciliary  body. 


Fig.  O'J. — Ciliary,  body  of  a  hyperopic 
eye  (specimen  prepared  by  Dr.  C.  M. 
Hosmer) . 


accommodation,  are  poorly  developed.  On  the  other  hand,  certain 
investigations  seem  to  indicate  that  the  imperfect  development  of  the 
ciliary  body  in  myopic  eyes  is  a  congential  default  and  is  not  the  result 
of  the  myopia,  but  may  be  a  determining  cause  of  it.  The  sinus  of  the 
anterior  chamber  is  deeper  than  it  is  in  enunetropic  or  hyperopic  eyes, 
and  hence  the  tendencj'-  to  primary  glaucoma  in  mj'opic  eyes  is  said  to 
be  lessened  (compare  however,  page  409). 


.. 


Fig. 


'0. — Manner  in  which  a  concave  lens  causes  rays  to  tlivcrjje  from  the  far  point  of 

a  myopic  eye. 


Determination  and  Correction  of  Myopia. — ^Myopia  may  bo  deter- 
mined: (1)  Hy  the  position  of  the  puintmii  proximutn  of  accommoda- 
tion, which  is  clo.scr  to  the  eye  than  is  normal  for  the  age;  (2)  by  the 
position  of  the  furthest  point  of  distinct  vision  obtaininl  by  test-types; 
(3)  by  the  oplitiialmoseopc  anil  retinoscope  (page  122);  (A)  by  the  con- 
cave glass  which  givers  (Ustinct  vision  at  a  distance  of  4  to  G  meters. 

Only  those  rays  which  diverge  from  a  distance  not  greater  than  the 
far  point  can  be  focui.scd  on  i\\v  retina  of  the  niyoi)ic  eye.  In  order  tiiat 
it  shall  see  at  any  greater  distance  than  this  the  rays  nuist  1)(>  given  a 
divergence  as  great  as  if  they  came  from  this  point  (Tig.  70).     If  the 


MYOPIA  141 

greatest  distance  at  which  a  myopic  eye  can  see  fine  print  is  14  cm., 
in  order  to  see  at  a  still  greater  distance  the  eye  would  require  a  con- 
cave glass  which  would  give  rays  a  divergence  as  if  they  came  from 
this  point.  By  dividing  100  by  14  we  obtain  the  number  of  diopters 
(7)  necessary  to  produce  this  divergence.  As  the  far  point  is  measured 
from  the  cornea,  the  glass  must  be  placed  close  to  the  cornea ;  if  the  glass 
is  removed  1  cm.  from  the  cornea,  it  is  plain  that  its  focal  point  will  also 
be  1  cm.  farther  away;  therefore  it  is  necessary  to  employ  a  glass  of 
shorter  focus. 

Example. — Suppose  it  is  desired  to  cause  the  rays  to  diverge  from  a  point  14  cm. 
in  front  of  the  cornea,  and  the  glass  is  to  be  placed  at  1.5  cm.  in  front  of  the  cornea ; 
it  is  evident,  in  these  circumstances,  that  the  glass  would  require  to  have  a  focus  of 

100 
14  —  1.50  =  12.5  cm.,  or  y^  =  8  diopters. 

The  proper  position  for  a  correcting  glass  is  at  the  anterior  focus  of  the  eye, 
that  is  about  13  mm.  in  front  of  the  cornea. 

In  low  degrees  of  myopia  this  does  not  affect  appreciably  the 
strength  of  the  glass,  but  in  the  higher  degrees  it  makes  a  serious 
difference.  The  concave  glass,  is  therefore,  somewhat  stronger  than 
the  actual  myopia,  especially  in  the  higher  grades. 

The  degree  of  myopia  may  be  determined  approximately  by  this 
method  more  rapidly  than  by  beginning  the  trial  at  6  meters  with 
glasses  (in  this  instance,  concave)  in  the  manner  already  described  in 
connection  with  hyperopia  (see  page  130).     One  example  will  suffice: 

A  patient  reads  fine  print  distinctly  at  8  cm.  from  the  cornea,  but  not  at  a 
greater  distance,  the  eye  being  under  the  influence  of  a  cycloplegic;  this  is  its  far 
point.  In  order  that  the  patient  may  see  at  an  infinite  distance,  parallel  raj^s  must 
be  given  a  divergence  as  if  they  came  from  8  cm.  in  front  of  the  cornea.  If  the 
glass  is  placed  13  mm.  in  front  of  the  cornea,  its  focal  length  will  be  8  cm.  —  1.3 

1000 
cm.  =  6.7  cm.,  or  67  mm.    py     mm.  equals  15  D,  as  the  number  of  the  concave 

lens  required  for  distant  vision.  A  lens  of  this  number  should  be  placed  in 
the  trial-frame,  and  the  vision  determined  through  it  by  means  of  test-types  at 
the  usual  distance.  Perhaps  a  weaker  or  a  stronger  lens  may  give  better  vision, 
and  hence  several  numbers  should  be  tried  in  succession,  until  that  glass  is  selected 
with  which  the  greatest  acuteness  of  vision  is  attained,  and  which  represents  the 
correcting  lens. 

A  patient  often  will  select  a  glass  of  higher  number  than  the  one 
really  required,  because  the  letters  have  a  blacker  and  sharper  appear- 
ance when  seen  through  concave  lenses;  but  unless  the  stronger  glass 
at  the  same  time  secures  for  the  patient  an  increased  acuteness  of 
vision  it  should  be  rejected,  and  the  weaker  lens  adopted.  If  several 
lenses  give  equally  good  vision,  the  weakest  one  should  be  chosen. 

The  method  of  determining  the  correcting  lens  in  myopia  by  means 
of  ophthalmoscopy  and  skiascopy  is  elsewhere  described  (see  pages  111 
and  122). 

Treatment  of  Myopia. — This  should  include  prophylactic  measures 
and  the  selection  of  suitable  concave  glasses.  From  the  eighth  to  the 
eighteenth  year — that  is,  during  school  life — myopia  tends  to  appear 


142  NORMAL   AND    .\BNORMAL   REFRACTION 

and  to  progress;  hence  prophylactic  means  are  urgently  required 
during  this  period.  No  child  should  be  permitted  to  begin  school 
duties  until  the  exact  state  of  the  refraction  has  been  determined. 
The  systematic  examination  of  children  in  primarj'  schools,  the 
correction  of  refractive  errors  especially'  astigmatism  and  beginning 
myopia,  the  elevation  of  acuteness  of  vision  to  the  normal  standard 
constitute  measures  of  paramount  importance.  Strict  attention 
should  be  paid  to  the  following  conditions:  A  correct  position  of  the 
head  and  body  during  study,  secured  by  means  of  a  suitable  desk,  the 
surface  of  which  is  so  tilted  that  the  page  of  the  book  lying  on  it  is  paral- 
lel to  the  scholar's  face,  and  by  a  chair  or  stool  of  proper  height  both 
in  relation  to  the  desk  and  the  floor;  the  employment  of  books  with 
sufficiently  largo  and  distinctly  printed  type ;  good  diffuse  illumination 
coming  from  behind  the  scholar  and  preferably  over  the  left  shoulder, 
and  therefore,  the  avoidance  of  glare  and  sharp  contrasts  of  light  and 
shade;  proper  ventilation;  restriction  of  the  hours  of  study  within 
reasonable  limits  and  plenty  of  outdoor  exercise.  These  precautions 
apply  with  equal  force  to  hours  of  stud}'  at  home. 

As  Priestley  Smith  has  well  said,  it  is  necessary  "to  suspect  every 
myopia,  and  especially  every  youthful  mvopia,  of  a  tendency  to  in- 
crease,until  time  has  proved  it  to  be  stationarj';  to  be  doubly  suspicious 
in  the  presence  of  congestion  or  atrophy  of  the  eye-ground;  and  to  re- 
examine at  intervals  of  six  months,  twelve  months,  or  longer,  according 
to  the  nature  of  the  case."  These  examinations  should  be  made  with 
the  help  of  mydriasis — if  possible,  with  atropin.  It  is  particularly  im- 
portant frequently  to  investigate  the  eyes  of  the  children  of  myopic 
parents.  In  some  cities — for  example  in  Berlin — a  special  curriculum 
is  provided  for  children  with  a  myopia  of  G  D  and  over  (Hirschberg). 
Harman  also  urges  that  children  with  high  degrees  of  myojiia  should 
be  instructed  in  special  classes. 

A  tendency  to  divergence  in  early  life,  has  sometimes  been  urged 
as  an  indication  for  tenotomy  of  the  external  rectus  to  prevent  the 
development  of  myopia.  It  is  questionable  whether  the  procedure  is 
satisfactory  in  this  regard. 

Since  Fukala's  recommendation  removal  of  the  crystalline  lens 
(discission,  followed  by  extraction,  or  phakohjsis)  has  been  practiseil 
by  a  number  of  operators  for  the  relief  of  high  myopia  (15  D  or  more). 
Improvement  in  vision  and  increase  in  the  distance  at  which  eyes  can 
be  used  in  near  work  are  the  results  of  successful  operations,  which, 
according  to  von  Hippel,  may  not  reach  their  best  standard  until  a 
year  after  the  operation — checking  of  the  increase  of  the  mvopia. 

The  chief  dangers  of  the  operation  are:  Intra-ocular  hemorrhngc, 
dctacinnent  of  tlu^  retina,  secondary  glaucoma  from  sw(>lling  of  the 
lens,  iritis,  ami  infection  of  the  corneal  wound.  Tlie  chief  contra- 
indications are:  Extensive  degeneration  of  the  choroid,  retina,  or 
vitreous,  diminished  intra-ocular  tension,  a  tendency  to  intra-ocular 
hemorrhage,  previous  loss  of  one  eye  from  any  cause,  and  a<lvance<l  ;ige. 
Hirschberg  vigorously  eoiKJeMiiis  any  tendency  to  indiscriminate  a|)pli' 


MYOPIA  143 

cation  of  the  operation  and  has  operated  only  on  carefully  selected  eyes. 
(For  methods  of  operating  see  pages  724, 725.)  The  author's  experience 
with  the  operation  has  been  very  limited,  but  it  has  been  favorable 
in  those  patients  whose  eyes  after  careful  study  have  been  selected  for 
operation.  He  believes,  however,  that  in  the  majority  of  cases 
correcting  lenses,  even  in  very  high  grades  of  myopia,  can  be  made  to 
serve  a  more  useful  purpose  than  operative  interference,  and  has  but 
rarely  found  it  necessary  to  advise  the  operation.  Hertel  has  designed 
telescopic  spectacles.  They  somewhat  resemble  an  automobile  goggle. 
They  decrease  the  size  of  the  visual  field,  but  increase  the  distinctness 
of  distant  objects.  They  are  intended  to  be  a  substitute  for  operative 
procedures  in  high  myopia.^  To  compute  the  probable  correcting 
glass  after  loss  of  the  crystalline  lens,  according  to  Landolt,  one  should 
divide  by  2  the  number  of  diopters  of  the  correcting  glass  of  the  complete 
eye,  and  when  concave,  subtract  it  from  11  D,  and  when  convex,  add 
it  to  11  D. 

Ordering  of  Glasses. — After  the  estimation  of  the  degree  of  myo- 
pia, astigmatism  having  been  excluded,  or,  if  present,  corrected,  the 
strength  of  the  glass  suitable  for  constant  use,  reading,  or  other  special 
work  must  be  determined.  This  is  decided  by  the  visual  acuteness,  the 
range  of  accommodation,  the  degree  of  the  myopia,  and  the  condition 
of  the  exterior  ocular  muscles. 

Young  people  (under  twenty)  with  good  vision  and  a  moderate 
degree  of  myopia  (6  D  and  under)  should  wear  the  full  correction  con- 
stantly if  the  accommodation  is  ample  and  no  signs  of  fatigue  are 
evident. 

Indeed,  full  correction  is  the  object  to  be  attained  for  young  persons 
with  normal  visual  acuteness  and  binocular  near  vision,  even  with 
higher  grades  of  myopia,  provided  the  lens  selected  shall  not  be  an 
overcorrection  when  brought  close  to  the  eye.  A  patient  wearing  a 
partial  correction  is  tempted  to  improve  distant  vision  by  looking 
obHquely  through  the  glass.  But  this  gives  it  a  cylindric  effect,  varying 
with  the  direction  of  the  visual  axis,  and  is  always  injurious.  The 
author  is  convinced  from  personal  experience  that  full  correction,  other 
things  being  equal,  yields  the  best  results  in  the  management  of  myopia, 
and  especially  in  the  prevention  of  its  increase,  and  this  conviction  is 
strengthened  by  the  abundant  statistical  information  on  this  subject 
which  has  been  collected  and  analyzed  by  observers  here  and  abroad. 
A  few  authors,  for  example,  Hirschberg,  are  not  in  accord  with  this 
advice.  Hirschberg  advises  that  if  the  myopia  is  beyond  3  D,  fully 
correcting  glasses  should  not  be  worn.  Naturally,  there  are  except- 
ions to  the  rule,  and  each  case  requires  thoughtful  study;  but,  in 
general  terms,  the  full  correction  of  myopia  yields  the  best  results 
because  the  eyes  are  placed  under  conditions  which  approximate  closely 
the  normal  both  for  distant  and  near  vision  and  the  function  of 
accommodation. 

Where  visual  acuteness  is  imperfect  or  binocular  vision  lost,  it 
1  See  Archiv.  f.  Ophthal.,   Bd.  Ixxv,  Heft  3,  p.  586,  1910. 


144  NORMAL    AND    ABNORMAL    REFRACTION 

may  be  necessary  to  order  a  partial  correction  for  near  work,  and  if  the 
patient  has  attained  those  years  when  accommodation  naturally  fails, 
he  must  be  provided  with  lenses  for  close  range,  or,  if  his  myopia  is  of 
suitable  degree,  read  without  glasses. 

In  high  grades  of  myopia  associated  with  lowered  vision  it  is  often 
necessar}'  to  diminish  the  full  correction  from  1  to  3  D.  It  is  evident 
that  the  greater  the  visual  acuteness,  the  farther  away  the  same  size 
of  tj'pe  can  be  seen;  hence  the  demand  on  accommodation  is  less  as  the 
visual  acuteness  is  greater. 

A  lack  of  accommodative  power  is  not  infrequently  evident  when 
comparatively  strong  concave  glasses  are  required  to  correct  the  exist- 
ing myopia,  but,  other  things  being  equal,  the  discomfort  which  this 
may  occasion  disappears  with  reasonable  rapidity  by  virtue  of  the 
evaporation  of  the  lacking  power. 

When  strong  concave  lenses  are  first  worn,  a  lack  of  accommodation 
often  appears,  which  is  Restored  by  a  few  months'  use  of  the  glasses. 
For  the  relief  of  this  deficiency  it  may  be  necessary  to  give  a  partial 
correction  for  near  work  imtil  ample  power  of  acconmiodation  is 
gained,  when  the  full  correction  should  be  used  for  all  purposes. 

Patients  who  have  long  been  accustomed  to  wear  partially  correct- 
ing glasses  for  all  purposes,  or  to  wear  a  full  correction  for  distance  and 
read  without  glasses  are  often  quite  unwilhng  to  change  their  habits 
in  these  respects.  Whether  they  should  be  advised  to  change  them 
naturally  depends  upon  the  S3'mptoms  which  exist,  the  condition 
of  the  eye  and  the  character  of  the  work  required  of  them.  Bifocal 
glasses — the  upper  portion  being  a  distance  glass  and  the  lower  segment 
a  +  1  or  1.5  D  often  serve  a  useful  j)urpose,  especially  in  office  work. 

As  age  advances  an  additional  glass  should  be  ordered  for  reailing 
which  will  give  the  patient  a  far  point  of  from  30  to  60  cm.  In  order 
to  obtain  this,  the  full  correction  must  be  diminished  from  1.50  to  3  D. 

The  position  of  tlu^  lens  used  to  correct  high  grades  of  myopia  is  of 
great  importance  (page  143).  The  nearer  the  lens  is  jjlacetl  to  the 
cornea,  the  stronger  it  becomes;  conversely,  the  farther  it  is  removed 
from  the  cornea,  the  weaker  it  is.  The  strong  concave  lenses  neces- 
sary to  correct  high  degrees  of  myopia  in  this  way  may  sometimes  be 
utilized  l)y  the  jjatient  to  gain  artificial  accomodation,  l^v  bringing 
them  close  to  the  eye  vision  is  adapted  for  distance;by  pushing  theni 
from  the  eye  divergence  is  lessened  and  the  eye  is  adapted  for  a  closer 
point. 

The  visual  acuteness  in  high  myopia  is  usually  reduced,  and  in 
thos(^  cases  a(^c()m))anied  l)y  changes  in  the  ictina  and  choroiil  this 
reduction  assumes  a  considerable  grade.  fc>ometimes  very  slight  im- 
provement in  distant  vision  is  secured  by  concave  glasses,  and  near 
vision  may  not  be  at  all  benefited.  In  these  circumstances  i)atii>nts 
se(!  better  by  using  one  eye  alone  and  bringing  the  print  or  other  work 
close  to  the  eye,  because  the  enlarged  retinal  image  comi)ensates  for  the 
diminished  visual  acuten(!ss.  'Hiese  cases,  however,  are  seUiom  en- 
countered,   and    a    concave  lens,    properly   selected,    almost    always 


ASTIGMATISM    (aSTIGMIA)  145 

improves  both  near  and  distant  vision.  Again  many  persons  require 
sharp  distant  vision  and  are  naturally  inconvenienced  in  its  absence. 
Therefore  it  must  be  remembered  that  the  glass  selected  while  the  eye 
is  under  the  influence  of  a  cycloplegic,  should  the  selection  have  been 
made  at  4  meters,  for  example,  will  be  an  under  correction  of  the  myopia 
of  0.25  D  after  the  effect  of  the  cycloplegic  drug  has  passed  away. 
The  glass  must  be  strengthened  by  this  amount  in  order  to  gain 
the  maximum  acuteness  vision  at  long  ranges. 

Concave  glasses  diminish  the  size  of  the  retinal  image,  especially 
when  the  glass  is  removed  farther  from  the  eye.  The  retinal  image  is 
larger  in  myopia  than  in  emmetropia,  but  if  the  correcting  lens  is  ex- 
actly 13  mm.  in  front  of  the  cornea,  the  image  is  of  the  same  size  as 
in  emmetropia. 

Concave  lenses  act  as  prisms  when  the  visual  line  passes  through 
any  portion  except  the  optical  center.  The  optical  centers  should 
always  be  separated  by  a  space  equal  to,  and  never  less  than,  the 
interpupillar}^  distance,  except  in  those  cases  of  weakness  of  the  in- 
ternal rectus  muscles  where  it  is  advisable  to  increase  the  distance 
between  the  centers.  This  produces  the  e'  ect  of  a  prism  with  its  base 
inward — ^that  is,  it  lessens  the  amount  of  convergence  which  otherwise 
would  be  required.  The  deviation  may  be  calculated  from  the  focal 
distance  of  the  lens  and  the  amount  of  decentering.  The  distance  the 
optical  center  is  displaced,  divided  by  the  focus,  equals  the  tangent  of 
the  angle  of  deviation.  Myopes  with  decided  esophoria  often  read 
more  comfortably  without  than  with  glasses. 

The  painful  glare  of  light  sometimes  caused  by  wearing  concave 
glasses  may  be  modified  by  tinting  them.  For  this  purpose  the  lighter 
shade  of  Crookes'  glass  serves  a  useful  purpose. 

The  reading-glasses  for  myopes  are  described  under  Presbyopia. 

Astigmatism  (Astigmia). — In  the  preceding  forms  of  ametropia, 
H.  and  M.,  the  cornea  has  been  considered  as  an  ellipsoid  of  revolution, 
so  that  planes  passing  through  it  in  various  directions,  vertical,  hori- 
zontal, and  oblique,  produce  sections  having  an  equal  curvature. 
Equal  refraction,  consequently,  takes  place  in  these  diflerent  planes. 
Variations  in  the  curvature  of  the  different  meridians  produce  differ- 
ences in  their  refractive  power;  in  some  of  these  meridians  the  eye 
roust,  therefore,  be  ametropic.     Thre^  conditions  may  arise: 

1.  The  eye  may  be  emmetropic  in  one  meridian  and  ametropic 
(either  H.  or  M.)  in  the  others. 

2.  The  eye  may  be  ametropic  (H.  or  M.)  in  all  meridians,  but  in 
different  degrees. 

3.  The  eye  may  be  ametropic  in  all  meridians,  but  in  some  H.  and 
in  others  M.  (H.  and  M.). 

It  is  convenient  to  designate  the  different  parts  of  the  eye  by  imagi- 
nary lines,  similar  to  those  employed  in  geography. 

The  axis  of  the  eye  is  a  line  drawn  from  the  center  of  the  cornea 
through  the  center  of  the  ball.  Passing  through  the  center  of  the  lens 
and  the  center  of  rotation,  it  penetrates  the  sclera  between  the  optic 

10 


146  NORMAL    AND    ABNORMAL    REFRACTION 

nerve  entrance  and  the  macula.     The  anterior  and  posterior  extremi- 
ties of  this  hne  are  the  poles  of  the  eye. 

A  great  circle  extentlinp;  round  the  ball  perpendicularly  to  the  axis, 
and  at  an  equal  distance  from  the  two  poles  is  called  the  equator  of  the 
eye;  other  great  circles  passing  through  the  poles  are  called  meridians. 

The  lens  is  described  in  a  similar  waj'  b}'  its  axis,  anterior  and  poste- 
rior poles,  and  equator. 

^AHien  the  meridians  of  the  cornea  have  an  equal  curvature,  the 
rays  of  light  gather  in  one  common  focus.  Frequently  the  cornea  has 
meridians  of  unequal  curvature  producing  greater  refraction  in  somo 
meridians  and  less  in  others.  The  rays  passing  through  the  meridian 
of  highest  refraction  reach  their  focus  soonest,  while  those  passing 
through  the  least  refracting  meridian  come  to  a  focus  farther  back. 

Definition. — Astigmatism  (or  astigmia)  is  an  ametropia  of  curvature, 
and  the  term  is  applied  to  that  refractive  condition  of  the  eye  in  which  a 
luminous  point — for  example,  a  star — -forms  an  image  on  the  retina,  the 
shape  of  ivhich  image  is  a  line,  an  oval,  or  a  circle,  according  to  the  situa- 
tion  of  the  retina,  but  never  a  point. 

Seat  of  Astigmatism. — Usually  the  cornea  is  the  seat  of  astigma- 
tism, but  astigmatism  may  also  be  produced  by  an  oblique  position  of 
the  lens  {lenticular  astigmatistn) ,  or  by  the  visual  line  passing  eccentri- 
callj'  through  the  cornea. 

When  the  meridians  of  the  cornea  progress  evenly  in  their  refrac- 
tion from  the  lowest  to  the  highest,  the  astigmatism  is  termed  regular. 
When  the  curvature  in  different  parts  of  the  same  meridian  varies  or 
successive  meridians  differ  irregularly  in  refraction,  or  the  meridians 
vary  irregularly  in  their  curvature  as  the  result  of  cicatrices  from  ulcers 
or  distention  of  the  cornea  from  inflammation,  the  astigmatism  is 
called  irregular. 

Almost  all  eyes  possess  more  or  less  irregular  astigmatism.  Usually 
it  is  only  slight,  and  gives  no  serious  inconvenience  for  ordinarj-  vision, 
but  all  points  of  light,  such  as  stars,  distant  street-lamps,  etc.,  shoot 
out  rays  and  twinkle  as  the  result  of  the  irregular  astigmatism  of  the 
eye.  The  seat  of  this  irregular  astigmatism  is  in  the  crystalline  lens  (so- 
called  "physiologic  astigmatism'').  In  the  lenses  of  young  people  the 
union  of  the  sectors  is  visible  by  three  faint  lines — the  lens  star;  in  the 
adult  secondary  rays  are  also  visible.  Slight  differences  in  the  density 
of  the  several  sectors  are  sufficient  to  produce  a  distorted  image  of  a 
luminous  point.  Should  pathologic  conditions  arise,  for  example,  begin- 
ning cataract,  lenticular  asligmatisnj  maybe  nuich  increased  (page  420). 

Principal  Meridians. — In  regular  jistigmatism  the  cornea  has  one 
meridian  witii  (he  shortest  radius  of  curvature  producing  the  highest 
refraction,  and  another  meridian,  at  right  angles  to  this,  with  the 
longest  radius  of  curvature  and  the  least  refraction.  Thes(^  are  called 
the  principal  meridians,  and  may  be  situatetl  in  any  part  of  the  cornea. 
but  there  is  a  disposition  of  the  greatest  refracting  meridian  to  lie  in  or 
near  a  vertical  direction.  ;in(l  of  the  least  refracting  meridian  to  lie  in 
a  horizontal  direction. 


ASTIGMATISM    (aSTIGMIA)  147 

If  the  meridian  of  greatest  refraction  is  vertical  or  nearly  so,  the 
astigmatism  is  described  as  direct  {astigmatism  "with  the  rule");  if  the 
meridian  of  greatest  refraction  is  horizontal  or  nearly  so,  the  astigma- 
tism is  spoken  of  as  inverse  (astigmatism  "against  the  rule");  if  the 
direction  of  the  principal  meridians  approaches  45°  and  135°,  the 
astigmatism  is  often  designated  oblique. 

To  simplify  the  phenomena  of  astigmatism  the  principal  meridians 
will  be  considered  as  running  vertically  and  horizontally  with  the 
greatest  refraction  in  the  vertical,  and  the  least  refraction  in  the 
horizontal,  meridian. 

Form  of  the  Image  of  a  Point  Focused  by  an  Astigmatic  Eye. — 
The  rays  passing  into  an  astigmatic  eye,  thus  considered,  are  most 
sharply  refracted  by  the  vertical  meridian.  The  bundle  of  rays, 
instead  of  having  a  round  section,  forms  a  horizontal  oval,  which 
becomes  smaller  as  the  rays  travel  farther  backward,  but  the  vertical 
diameter  of  the  oval  lessens  most  rapidly  until,  when  the  focus  of  the 
vertical  meridian  is  reached,  the  figure  becomes  a  horizontal  line, 
because  all  the  rays  are  brought  to  one  level  and  remain  diffused  only 
in  the  horizontal  direction. 


'A   A-^//  h^^H     h^>--.h        h-''         fi\h        h-~-r-h 


Fig.  71. — Retinal  images  of  a  point  in  the  different  forms  of  astigmatism:  A,  Com- 
pound hyperopic  astigmatism;  B,  simple  hyperopic  astigmatism;  C,  D,  E,  mixed  astig- 
matism; F,  simple  myopic  astigmatism;  G,  compound  myopic  astigmatism. 

Farther  back  the  rays,  after  passing  this  focus  and  crossing,  diverge 
again  vertically,  and  the  figure  becomes  once  more  a  horizontal  oval; 
but  shorter  because  the  horitonzal  diffusion  is  diminished. 

Still  farther  the  figure  assumes  the  form  of  a  circle;  the  diffusion  of 
the  horizontal  rays  has  become  less,  and  that  of  the  vertical  rays  more. 
The  figure  becomes  next  a  vertical  oval,  then  a  vertical  Hne  as  the  focus 
of  the  horizontal  meridian  is  reached.  Finally,  the  section  is  again  a 
vertical  oval,  the  horizontal  rays,  having  passed  their  focus,  cross  and 
begin  to  diverge  (Fig.  71). 

It  is  evident  from  this  that  no  matter  what  position  the  retina  may 
occupy,  no  distinct  image  can  be  formed  upon  it,  but  there  must 
always  be  overlapping  of  the  images  of  the  different  points  of  an 
object,  causing  a  blur  or  a  wrong  impression  of  its  outline. 

The  focusing  of  light  by  an  astigmatic  eye  is  further  illustrated 
by  a  figure  and  description  borrowed  from  Edward  Jackson  as  follows: 
In  this  figure  VV  represents  the  meridian  of  greatest  curvature  and 
HH  the  meridian  of  least  curvature.  Vertically,  in  the  direction  of 
VV,  all  the  rays  above  and  below  are  turned  down  and  up  to  such  an 
extent  that  they  are  brought  to  the  level  of  the  central  ray  at  F.  But 
horizontally,  in  the  direction  of  HH,  they  are  not  turned  to  such  an 


148 


NORMAL  AND  ABNORMAL  REFRACTION 


extent  bv  the  weaker  curvature,  and  do  not  come  into  line  with  the  cen- 
tral rav  until  they  reach  G.  The  ray.  are  converged  m  both  cliroctions 
but  unequally,  so  that  at  F,  being  alUathered  to  tl^ -""f  ,^'^'^1 ;" 
still  spread  out  laterally,  they  form  a  horizontal  focal  line  FI .  Then 
the  r^vs  bedn  to  spread  up  and  down,  although  still  gathering 
ogelhor  from  the  sides,  until  at  G  they  are  collected  in  the  vertical 
focal  line  GG.  Beyond  G  they  spread  out  in  all  directions.  FF  is 
called  the  anterior  focal  line,  and  GG  the  posterior  foca  line.  The 
distance  between  the  focal  lines  is  the  focal  interval  of  bturm. 


Fig.  72.-Refraction  of   light   in    principal    -«^"dians  of  an  astigmaticje.^^^^^^^^^^^^ 
part  representing  the  vertical,  and  the  lower  part  the  horizontal  mendiau  (Jackson). 

Symptoms.-From    what   has   been    recorded    in    t^e   preceding 
paragraphs  it  follows  that  the  acuteness  of  vision  is  ^l»^;;"f  ^^     ^ 
astigmatism.     Letters   are   not    distinctly   seen,    some  /^tter.       mg 
confused  with  others-H  and  N,  B  and  S.  F  and  P.  !■  and  R  ^    ^uA  M 
K  and  X    V  and  Y.     The  overlapping  of  the  d.tlusion  aiea..  m  the 
retinal  image  produces,  in  high  .legrees  of  astigmatism,  an  appareii 
^bhng  oMhe  obiect.     The  indistinctness  of  vision  -"l-l;; ^-^^ 
approximation    of    the   object,    with    a   consequent    sttam    upon    t   e 
ac'.mmodation.     Although    low    degrees    of    -J'^^f -"J::>J  f 
compatible  with  fairly  distinct  vision  this  does  not  exclude  ^^>^-t     "U 
Is  the  amount  of  this  refractive^  cU>fect  increases  the  acuteness  of  v..  on 
dhninishes.     The  effort  to  see  clearly  and  the  frequent  apparent  nun  (^ 
mcnt  and  dancing  ol  small  objects,  such  as  letters,  add  materially  to 
the  discomfort  of  the  subjects  of  astigmatism  (soo  jilso  paj     1^1   • 
Ast  igmat .c  p.'rsons  hsun  to  overcome  their  refractive  <lefcc    b>  .  o 
tracting  the  lids  close  togc-tlu-r  in  order  to  inake  a  »-'•';-'";;  .;''':,,,,V: 
vertically    .Hvcrgcnt    rays    arc    thus    excluded,    and    tl>e    e>e.    .,c .  on. 

;.-  a  e  n..t  of  so  nmrh  .■ons...„u-n.-e  in  .lefrnnmnK  th.  .\rnruv..  of  ^  ..mou  • 
tlM   way  in  whirl,  th,-  li^ht  .s  conc-.-ntratod  ...  tho  .UtTumon  ..naKC. 


ASTIGMATISM    (aSTIGMIA) 


149 


modated  for  the  horizontally  divergent  rays,  receives  a  more  distinct 
though  fainter  image.  There  is  an  almost  characteristic  facial  expres- 
sion in  astigmatism  caused  by  contraction  of  the  lids. 

Astigmatism  produces  an  indistinctness  in  the  appearance  of  fine 
lines  running  in  certain  directions,  the  direction  of  the  indistinct  lines 
being  determined  by  that  meridian  which  has  its  focus  on  or  nearest 
to  the  retina.     This  meridian,  therefore,  will  most  nearlv  approach 


Fig.  73. — Rays  passing  through  an  astigmatic  lens  (Thorington). 


emmetropia;  the  lines  parallel  to  it  will  appear  indistinct,  while  those 
parallel  to  the  opposite  meridian,  or  the  one  farthest  removed  from 
emmetropia,  are  most  distinctly  seen. 

In  those  cases  in  which  the  horizontal  meridian  is  emmetropic  and 
the  vertical  meridian  ametropic,  fine  parallel  lines  running  in  a  hori- 
zontal direction  will  appear  spread  out  into  thick  bars,  while  vertical 
lines  will  appear  distinct. 

To  understand  this,  the  student  should  remember  that  rays  diverge 
from  a  horizontal  line  in  all  directions;  those  which  pass  through  the 
horizontal  meridian,  if  they  are  not  exactly  focused,  spread  out  in  the 
direction  of  the  line,  causing  its  extremities  to  appear  somewhat  faint 
in  outline,  but  do  not  blur  its  width. 
The  rays  which  diverge  in  vertical 
planes  from  the  different  points  in 
the  line  pass  through  the  vertical 
meridian.  If  this  is  not  emmetro- 
pic, the  breadth  of  the  line  appears 
thicker;  but  if  the  vertical  meridian 
is  emmetropic,  it  forms  a  distinct 
point  in  the  image,  of  each  point 
in  the  object,  by  bringing  the  rays 
which  pass  through  it  to  a  focus. 
A  horizontal  hue  thus  appears  as  a  succession  of  distinct  points  when 
the  vertical  meridian  is  emmetropic.  Vertical  lines,  in  the  same  way, 
appear  most  distinct  when  the  horizontal  meridian  is  nearest  to 
emmetropia,  or  if  oblique  lines  appear  most  distinct,  the  meridian  at 


Fig.  74. — Illustrating  the  appearance 
of  lines  running  in  different  directions  as 
seen  by  (a)  the  normal  eye  and  (6)  the 
astigmatic  eye  (Jackson). 


150  NORMAL    AND    ABNORMAL    REFRACTION 

right  angles  to  their  direction  i^;  the  one  nearest  to  enimetropia.  Lum- 
inous points  are  drawn  out  in  the  direction  of  the  ametropic  meridian, 
and  luminous  circles  become  elongated  into  ovals. 

Astigmatism  may  be  responsible  for  the  most  aggravated  types  of 
asthenopia  and  most  marked  symptoms  of  eye-strain.  Fully  70  per 
cent,  of  functional  headaches  are  caused  by  this  type  of  refractive  error, 
either  alone  or  in  association  with  other  forms  of  ametropia.  The 
headache  may  vary  from  a  moderate  frontal  distress  to  violent  ex- 
plosions of  pain,  and  may  be  situated  in  any  portion  of  the  cranium. 
That  true  migraine  is  caused  by  astigmatism  alone  is  doubtful;  that  the 
correction  of  astigmatism  is  an  important,  indeed,  an  essential,  part  of 
the  treatment  of  this  affection  should  not  be  disputed.  Furthermore, 
all  manner  of  reflex  nervous  disturbances,  vertigo,  pseudochorea,  habits 
spasm,  epileptiform  convulsions,  melancholia,  neurasthenia,  tachycar- 
dia, night-terrors,  flatulent  and  other  types  of  dyspepsia,  indigestion, 
and  even  constipation  are  the  frequent  results  of  astigmatism,  not  only 
when  the  error  is  of  high  degree,  but  commonly,  indeed,  more  commonly 
when  it  exists  in  low  grade,  and  often  unassociated  with  any  symp>- 
toms  which  prominently  direct  attention  to  the  eyes  as  the  cause  of  the 
distress.  Pains  strangely  and  persistently  situated  in  the  nape  of  the 
neck,  between  and  under  the  shoulder-blades,  in  the  precordium,  at 
the  end  of  the  spine,  and  deep  in  the  mastoid  may  owe  their  origin  to 
the  same  cause.  Tilting  of  the  head  and  shoulders  is  often  the  result  of 
astigmatism,  and  that  the  same  refractive  anomaly  is  the  exciting  cause 
of  some  of  the  cases  of  lateral  curvature  of  the  spine  so  often  seen  in 
young  subjects  has  been  shown  by  G.  M.  Gould.     (See  also  page  613.) 

Regular  astigmatism  is  divided  into  five  varieties,  according  to  the 
relative  position  of  the  retina  to  the  foci  of  the  two  principal  meridians. 
The  focus  of  the  horizontal  meridian  is  represented  by  H.,  that  of  the 
vertical  meridian  b\'  V. 

1.  Simple  Hyperopic  Astigmatism. — In  this  variety  one  meridian, 
more  frequently  the  vertical,  is  emmetropic,  and  the  horizontal  meridian 
is  hyperopic.  The  focus  of  the  vertical  meridian  is  on  thf>  retina;  the 
focus  of  the  horizontal  meridian  is  behind  the  retina  (Fig.  75) ;  horizontal 
lines  appear  distinct. 

2.  Simple  Myopic  Astigmatism. — Thc^  focus  of  one  meridian, 
frequently  the  horizontal,  is  situated  on  the  retina,  while  tlu^  focus  of 
the  vertical  meridian  lies  in  front  of  the  retina.  The  vertical  meridian 
is  myopic,  and  the  horizontal  meridian  emmetropic  (,Fig.  7t)):  vertical 
lines  appear  distinct. 

3.  Compound  Hyperopic  Astigmatism.  All  meridians  iwc  hypt>r- 
oi)ic,  but  inoic  Iretjueiitly  t he iioiizontal  present.'^  thegreatest  anuMropift. 
The  foeus  of  each  piincipal  meridian  is  .•situated  back  of  the  retina,  that 
of  the  vertical  generally  being  iieansi  to  it  i  l''ig.  77);  horizontal  lines 
are  usually  most  distinct. 

4.  Compound  Myopic  Astigmatism.  All  meridians  are  myt)pic, 
but  the  vertical  presents  the  greatest  ametropia.  Both  principal 
meridians  have  their  foci  in  front  of  the  retina,  that  of  the  horizontal 


ASTIGMATISM    (aSTIGMIA) 


151 


lying  closer  to  the  retina  (Fig.   78);  vertical  lines  are  usuallj'  most 
distinct. 

5.  Mixed  Astigmatism, — The  retina  lies  between  the  foci  of  the  two 
principal  meridians.  The  horizontal  meridian  is  hyperopic,  and  the 
vertical  meridian  is  myopic  (Fig.  79) ;  no  hnes  appear  distinct  unless 


Fig.  75. — Foci  of  the  principal  meridians     Fig.  76. — Foci  of  the  principal  meridians 
in  simple  hyperopic  astigmatism.  in  simple  myopic  astigmatism. 

the  eye  simulates  myopic  astigmatism;  in  this  case  the  vertical  lines 
appear  distinct. 

It  must  be  remembered,  as  Jackson  has  well  shown,  that 
astigmatism  is  likely  to  change  at  any  period  of  life  and  it  frequently 
increases  because   of   the  increased  asymmetry  of  the  anterior  sur- 


FiG.  77. — Foci  of  the  piincipal  meridians     Fig.  78. — Foci  of  the  principal  meridians 
in  compound  hyperopic  astigmatism.  in  compound  myopic  astigmatism. 

face  of  the  cornea  in  childhood.     Inverse  astigmatism  is  infrequent 

among  children,  rarely,  if  ever  occurring  prior  to  the  tenth  year  of  life ; 

it  is  probably  more   common  in  females  than  in  males.     Jackson's 

statistics,  and  with  these  statistics  those  of  the  author  are  in  entire 

accord,   indicate    that    direct    astigmatism   is 

the  exception  in  the  latter  part  of  hfe  when 

inverse  astigmatism  is  much  more  commonly 

encountered.     John    Green,    Jr.    and   W.   F. 

Hardy    maintain    that    inverse    astigmatism 

appears  to  be  nearly  as  frequent  from  birth 

to  middle  age,  as  from  middle  age  to  old  age. 

Recognition  of  Astigmatism. — Astigmatism 
is  recognized  subjectively  by  the  greater  dis- 
tinctness of  lines  which  run  in  one  direction, 
and  the  blurring  of  those  lines  which  run  in  a  direction  at  right  angles  to 
this  (see  Fig.  74).  The  vertical  strokes  of  a  letter  may  appear  distinct, 
while  the  horizontal  strokes  are  hazy. 

A  diminished  visual  acuteness,  unimproved  by  spheric  lenses,  in 
the  absence  of  organic  disease  of  the  eye, — for  example,  opacity  of  the 


Fig.  79. — Foci  of  the  prin- 
cipal meridians  in  mixed  as- 
tigmatism. 


152  NORMAL    AND    ABNORMAL    REFRACTION 

modia  or  losions  of  the  fuiulus.  or  lesions  of  the  visual  centers.— usually 
is  due  to  astigmatism.  Letters  have  a  streaked  or  smeared  appear- 
ance; a  small  jet  of  flame  seems  to  be  drawn  out  in  one  direction 

(see  also  page  148).  .  ,    ,    i  /.^^ 

Astigmatism  is  recognized  objectively  V,y  the  ophthalmoscope  (see 

pages  111  to  114),  the  ophthalmometer  (seepage  110  and  Appendix),  and 

skiascopy  (see  page  117). 

Correction  of  Astigmatism.— Astigmatism  may  exist  m  a  very  lovs 
degree,  associated  with  a  much  higher  degree  of  hyperopia  or  myopia, 
or  a  marked  astigmatism  may  exist  alone,  or  with  ametropia  of  the 
other  meridians,  or  finally,  mixed  astigmatism  may  be  present,  i  here 
are  several  methods  bv  which  astigmatism  may  be  measured. 

1.  In  all  cases  of  hvperopia  or  myopia,  after  the  highest  visual 
acuteness  has  been  developed  with  spheric  lenses,  and  even  it  the 
radiating  lines  on  the  dial  appear  equally  distinct,  a  weak  convex 
and  a  weak  concave  cylindric  lens  should  be  alternately  placed  in 
the  trial-frame,  in  addition  to  the  spheric  lens,  and  their  axes  rotated 

'n^bv  this  maneuver,  vision  is  improved  and  the  patient  enabled 
to  read  another  Une  of  the  test-letters,  astigmatism  is  present,  tor 
example,  if  the  vision  of  a  case  of  hyperopia  of  3D  is  improved  by 
placing  in  front  of  the  spheric  lens  a  convex  0.50  D  cylinder,  wi  h  its 
axis  vertical,  the  glass  required  is  +  3  D  sph.  C  +  O.oO  cyl,  axis  90  or 
vertical-  but  if  in  the  same  case  the  maximum  vision  previously  ob- 
tained bv  +  3  D  sph.  is  not  improved  by  the  addition  of  a  convex 
cylindric^lens,  a  concave  cyUndric  lens  should  be  rotated  through  1»U 
in  front  of  the  spheric  lens.  If,  in  these  circumstances,  a  concave 
cylinder  of  0.50  D  with  its  axis  at  180°  is  found  to  improve  vision  and 
equalize  the  lines,  the  formula  is  +  3  D  sph.  C  '  0.50  D  cyl..  j^^^'^lf  ^ 
This  result  may  be  expressed  in  a  simpler  form  by  the  fornuda  +  -OU 
Dsph.^  +  0.50  D  cyl.,  axis  90°  (see  page  32). 

From  this  it  is  evident  that  any  spherocylindrie  combination,  in 
which  the  spheric  is  designated  by  a  plus  (  +  )  and  the  cylinder  by  a 
minus  (-)  sign,  unless  the  cylinder  is  stronger  than  the  spheric,  can  >e 
reduced  to  a  simpler  form,  obtained  by  subtracting  tiie  value  ol  the 
cylinder  from  that  of  the  spheric  lens;  the  difference  is  the  streiiMh 
of  the  refjuired  spheric  lens.  A  cylinder  of  \hr  .ame  strength  as  tlie 
one  first  emi.loyed.  with  its  sign  ehanged  to  correspond  to  that  ol 
the  spheric  lens,  and  the  axis  reversed,  completes  the  |)rocess.  i  m^ 
method  of  correcting  astigmatism  is  best  adapted  to  tliose  case>  in 
which  the  degree  is  0.75  D  or  less. 

2  The  position  of  the  principal  meridians  is  determine.!  by  meaiu. 
of  the  clock-face,  SnelL-n's  <lial.  or  a  seri.>s  of  lines,  as  is  shown  in  Mg.  hU 
and  especially  well  with  Lanca.ster's  charts. 

The  m-ost  distinct  lines  correspon<l  t,.  the  most  aiuetropie  meridian 
therefore  a  sU'noi>oir  slit  is  inserted  in  \Uv  trial-frame,  in  a  direction  ai 
right  angles  to  tliis.     If  visi..n  is  imnual  in  this  din«et.on    the  meridian 
must  be  enunetropic  and  the  a.stigmatism  is  .sunple.      I  he  sht  i>  tnen 


ASTIGMATISM    (aSTIGMIA) 


153 


turned  at  right  angles  to  its  previous  direction,  and  the  glass  found 
which  gives  the  highest  vision.  The  astigmatism  is  represented  bj- 
this  glass.     The  following  are  examples: 

Simple  Hyperopic  Astigmatisvi. — The  patient  sees  horizontal  lines  most   dis- 
tinctly; the  stenopaic  slit  is  placed  verticalh^  in  front  of  the  ej-e:  and  through  this 

F  =  s;  with  the  stenopaic  slit  horizontally  placed,   V  =  5,    with   +  1  D   added, 

y  =  ^;  hence  +  1  D  cyl.,  axis  90°,  is  the  glass  required. 

Simple  Myopic  Astigmatism. — -The  patient  sees  vertical  hnes  most  distinctly; 
the  sht  is  placed  horizontal!}' :  T'  =  ^;  with  the  slit  placed  vertically:  V  =  Yo,  ^^i^^ 

—  1.50  added,  T'  =  g;  hence  —  1.50  cyl.,  axis  180°,  is  the  glass  required. 


®(90 

Fig.  80. — Wallace's  astigmatic  chart  reduced  to  one-sixth  of  its  diameter. 

3.  The  patient  ma\^  not  perceive  any  difference  in  the  distinctness 
of  the  radiating  lines  until  a  spheric  lens  is  placed  in  front  of  the  eye, 
when  some  of  them  become  more  distinct  than  the  others.  The  slit 
is  now  introduced  in  a  direction  at  right  angles  to  the  distinct  lines. 
Vision  is  not  normal,  but  a  spheric  lens  improves  it,  and  that  lens  which 
gives  the  best  vision  with  the  slit  in  this  direction  is  selected.  The  slit 
is  then  reversed.  The  visual  acuteness  is  less  through  the  slit  in  this 
position  than  in  the  previous  one,  and  a  higher  lens  is  necessary  to  se- 
cure the  best  vision.  The  astigmatism  is  represented  by  the  difference 
between  the  stronger  and  the  weaker  lens.  This  is  an  example  of  com- 
pound astigmatism,  and  is  corrected  b}^  a  spheric  lens  of  the  same 
strength  as  that  which  neutralizes  the  least  ametropic  meridian,  and  a 
cylindric  lens  equal  to  the  difference  between  the  two  meridians.  The 
following  are  examples : 


154  NORMAL   AND    ABNORMAL   REFRACTION 

Compound  Hyperojnc  A-stiytnati.sm. — No  lines  appear  (iistinct,  or  perhaps  the 
horizontal  ones  only  slightly  more  distinct  than  the  others,  but  a  convex  glass 
makes  the  horizontal  lines  decidedly  more  distinct.     The  slit  is  introduced  in  a 

vertical  direction:   V  =  .^J  ^vith  -f  l.oO  spheric  lens  added,  ^    =  j;"     The  slit  ia 

now  turned  in  a  horizontal  direction:  V  =  oq)  with  +  3.50  D  sph.  added.  V  =  »• 

The  glass  required  for  such  a  case  is  +  1.50  D  sph.  C  +  2  D  cyl.,  axis  90". 

Compound  Myopic  Astigmatism. — No  lines  are  distinct,  but  a  concave  spheric 
lens  possibly  makes  the  vertical  lines  more  distinct  than  the  others,  if  the  visual 
acuteness  is  not  too  much  lowered.  The  slit  is  introduced  in  the  horizontal  direc- 
tion: V  =  j,^;with  —  5  D  added,  V  =  ^2      The  slit  is  now  placed  vertically:  V  = 

ft  (\ 

^pj,  —  7  D  is  added,  and  V  rises  to  jn'     The  glass  required  is  —  5  D  sph.  3  —  2  D 

cyl.,  axis  180°. 

All  that  has  been  said  in  regard  to  the  selection  of  glasses  in  myopia 
applies  equally  here.  It  is  often  impossible  to  correct  the  astigmatism 
accurately  in  the  manner  just  described,  and  better  results  are  obtained 
by  the  first  method — that  is,  by  developing  the  best  possible  vision  with 
spheric  lenses,  and  then  adding  cylinders  to  still  further  improve  the 
visual  acuteness. 

Mixed  Astigmaiism. — Hyperopia  exists  in  one  principal  meridian, 
and  myopia  in  the  other.  Usually  no  set  of  lines  appears  plainer  than 
the  rest,  but  the  addition  of  a  concave  or  convex  spheric  lens  brings  out 
some  lines  more  distinctly  than  the  others.  Thus  a  clue  to  the  princi- 
pal meridians  is  obtained.  With  the  slit  before  the  eye,  a  convex 
spheric  lens  is  placed  in  position  and  the  slit  rotated  until  the  vision 
becomes  more  distinct.     The  hyperopic  meridian  has  then  been  found. 

Example. — Suppose  the  hyperopic  meridian  to  be  horizontal  and  V  to  be  most 
improved  by  -f  3  D.  The  slit  is  turned  to  the  vertical  position,  and  it  is  found 
that  a  —  4  D  gives  the  best  vision.  The  difference  between  these  two  meridians 
is  7  D.  A  +  7  cylinder,  axis  90°,  placed  before  such  an  eye  would  produce  a 
myopia  of  4  D,  while  a  —  7  cylinder,  axis  180°,  would  produce  a  hyperopia  of  3  D, 
consequently  with  the  +  7  cylinder  we  must  associate  a  —  4  spheric  lens,  and  with 
the  —  7  D  cylinder  a  +  3  D  spheric  lens.  Such  a  case  could  be  corrected  by 
either  of  the  following  formulas:  +  3  D  sph.  C  —  7  D  cyl.,  axis  ISO^;  or  —  4  D 
sph.  3+  7  D  cyl.,  a.xis  90°;  or  bj'  means  of  two  cylindric  lenses  with  their  axes  at 
right  angles  to  each  other,  viz.,  +  3  D  cyl.,  axis  90°  C  —  4  D  cyl.,  a.xis  180°,  (see 
also  page  32). 

Dr.  J.  8.  Johnson,'  of  8t.  Paul,  employs  a  method  of  dc^tciinining 
astigmaiism  which  he  calls  "the  reversal  of  the  dock-dial  chart"  when 
it  is  viewed  through  successive  spheric  len.ses.  The  liist  inihcatioii  of 
such  a  change  nuuks  the  dividing  line  between  the  hyperopia  and  the 
astigmatism  and  between  the  spheric  and  cylindric  correction.  If 
carried  carefully  to  the  point  of  complete  reversal,  it  will  also  show 
the  ametropia  of  iiighest  degree  and  thus  serve  all  the  purposes  of  the 
stenopaic  slit. 

Thorington  also  utilizes  this  method  in  deteiinining  the  acuteness 
of  vision,  which  he  maintains  uniler  definite  comhtions  is  ;in  index  of 

'  Oplilliiilniic  He<M.nl.  Octnb.T.  l<.>ni. 


ASTIGMATISM    (ASTIGMIA)  155 

the  strength  of  the  spheric  lens  which  will  give  normal  vision.  For 
this  purpose  he  has  designed  a  series  of  "metric  test-letters  and  lines." 

The  astigmatic  lens,  or  crossed  cylinder,  as  pointed  out  by  Edward 
Jackson,  is  most  useful  to  determine  the  amount  and  also  the  principal 
meridians  of  astigmatism.  This  astigmatic  lens  is  employed  as  a 
supplementary  lens;  the  axis  of  the  cylinder  is  first  placed  in  the  same 
direction  as  the  axis  of  the  cylinder  in  the  trial-frame,  and  next  it  is 
turned  perpendicular  to  it.  In  one  position  it  enhances  the  effect  of  the 
cylinder  in  the  trial-frame ;  in  the  other  it  diminishes  the  effect.  There- 
fore, if  the  vision  is  unchanged  by  an  astigmatic  lens  in  either  of  these 
positions,  the  cylinder  in  the  trial-frame  is  correct.  If  the  vision  is 
improved  by  the  astigmatic  lens  when  placed  in  one  position,  but  not 
made  better  in  the  other  position,  the  cylinder  in  the  trial-frame  must 
be  changed  accordingly,^  Various  astigmatic  lenses  may  be  used  hav- 
ing a  value  of  ID  (  +  50  cyl.  C-0.50  cyl.),  0.50  D,  and  0.25  D. 

The  following  additional  facts  concerning  lenses  require  mention: 
If  a  spherocylinder  is  in  position  before  an  eye,  and  vision  is  improved 
by  placing  before  it  another  cylinder  of  the  same  sign  (  +  or  — ),  with 
its  axis  at  right  angles  to  that  of  the  first,  it  shows  that  a  stronger 
spheric  and  weaker  cylinder  are  required. 

If  vision  is  improved  by  placing  in  position  another  cylinder  of  the 
same  sign,  with  its  axis  parallel  to  the  first,  it  shows  that  the  same 
spheric  with  a  stronger  cylinder  should  be  adopted. 

If  vision  is  improved  by  placing  in  position  a  cylinder  of  dif- 
ferent sign,  with  its  axis  parallel  to  the  first,  it  shows  that  a  weaker 
cylinder  with  the  same  spheric  lens  is  needed. 

If  vision  is  mproved  by  placing  in  position  another  cylinder  of  dif- 
ferent sign,  with  its  axis  at  right  angles  to  the  first,  it  shows  that  a 
weaker  spheric  lens  with  a  stronger  cylinder  must  be  employed. 

4.  Astigmatism  is  best  estimated  and  the  correcting  glass  deter- 
mined by  objective  methods:  skiascopy  and  the  ophthalmometer.  These 
have  been  referred  to  and  are  elsewhere  explained  (see  pages  116 
and  117.) 

All  methods  should  be  tried  before  the  glass  is  finally  ordered, 
and  the  highest  visual  acuteness  possible  should  be  obtained. 

Ordering  of  Glasses. — Glasses  are  ordered  for  astigmatic  eyes 
according  to  the  general  rules  already  given.  For  distance,  the  full 
correction  is  ordered  in  myopic  astigmatism  and  usually  in  mixed 
astigmatism;  in  compound  hyperopic  astigmatism  the  spheric  lens  is 
usually  weakened  to  meet  the  requirements  of  accommodation,  but 
the  full  cylindric  lens  should  be  ordered.  In  simple  hyperopic  astig- 
matism it  may  be  necessary  to  add  a  concave  spheric  lens;  thus,  if  the, 
correction  under  full  mydriasis  at  4  meters  should  prove  to  be  +1.50 
D  cyl.,  axis  90°,  the  formula  for  the  glass  to  be  worn  after  return  of  ac- 
commodation would  be- 0.25  D  sph.  C  +  1-50  D  cyl.,  axis  90°. 
In  compound  myopic  astigmatism  the  spheric  lens  is  sometimes  weak- 
ened for  near  work.     Simple  myopic  astigmatism  and  mixed  astigma- 

^  For  full  directions  in  regard  to  the  use  of  the  lens  see  article  by  E.  Jackson, 
Ophthalmic  Record,  August,  1907. 


156  NORMAL    AND    .ABNORMAL    REFRACTION 

tisin  givp  an  opportunity  for  simplifying  reading-glasses,  as  will  be 
{lescribod  under  Presbyopia. 

At  present  there  is  no  uniform  plan  for  the  designation  of  the  mer- 
idians in  astigmatism,  and,  consequently,  formulas  for  glasses  intended 
to  correct  astigmatism  do  not  have  a  uniform  meaning  in  all  parts  of  the 
world.  Drs.  Thomson  and  Harlan^  have  conveniently  summarized 
three  systems  as  follows: 

1.  The  zero  is  placed  at  the  end  of  the  horizontal  meridian  to  the 
patient's  left,  and  the  degrees  are  counted  on  the  upper  semicircle  to 
180°  at  his  right. 

2.  Zero  is  placed  at  the  top  of  the  vertical  meridian,  and  the  de- 
grees are  counted  to  the  nasal  and  temporal  sides  to  90°  at  the  hori- 
zontal meridian. 

3.  The  zero  mark  is  placed  at  the  nasal  extremity  of  the  horizontal 
meridian  in  each  eye,  and  the  degrees  are  counted  on  the  upper  semi- 
circle to  180°  at  the  temporal  extremity. 

The  first  is  the  one  in  almost  universal  use  in  this  country,  the 
formula  for  the  glasses  being  written  in  accordance  with  the  markings 
on  the  trial-frame. 

Irregular  Astigmatism. — A  low  degree  of  this  defect  exists  in  nearly 
all  eyes,  but  it  does  not  interfere  with  good  vision.  When  its  degree 
is  increased  by  irregularities  of  the  corneal  surface  from  keratitis  and 
cicatrices,  the  vision  is  very  much  reduced,  and  where  such  lesions  arc 
extensive,  optical  therapeutics  may  be  unavailing.  Often,  however, 
within  the  pupil  space  small  areas  may  be  found  in  which  the  refraction 
is  tolerably  uniform,  and  vision  may  be  decidedly  improved  l)y  lenses — 
spheric  and  cylindric.  All  such  eyes  should  be  carefully  studied  by 
objective  methods,  and  full  trial  with  lenses  should  be  made.  Steno- 
paic  spectacles  render  vision  more  distinct.  l)ut  they  embarrass  the 
wearer  by  limiting  the  field  of  vision.  An  iridectomy  sometimes  im- 
proves vision  by  tlisplacing  the  pupil  toward  a  more  regular  portion 
of  the  cornea. 

Surgical  Treatment  of  Astigmatism. — It  lias  l)een  propo.«^ed  to 
corre(;t  astigmatism  l)y  incising  the  cornea  with  a  (iraefe  knife,  or  l>y 
producing  a  wound  two-thirds  of  the  depth  of  the  cornea  with  the 
galvanocautery  (Laus).  The  operation  should  l)e  performed  on  the 
meridian  of  greatest  refiaction  (Borsch).  The  nutlior  has  had  no  ex- 
perience with  these  procedures. 

Anisometropia.'-- -Tliis  terni  includes  cases  in  whicli  one  eye  is 
much  nioic  liyperopic  or  myopic  than  its  fellow,  or  where  one  eye  is 
astigmatic  and  the  other  not,  or  where  myopia  exists  in  one  eye  and 
hyperopia  in  the  other.         Anisometroj)ia  may  be  congenital  or  may 

'  Arcliivcs  of  ( )|)litli;iliii(il()ny,  ISi).i,  vol.  wii,  pp.  "J")!  2(11.  'iliis  paper  coiit.-iins 
ail  cxccllcii),  (liscussioii  uf  tins  suWjfct  mikI  an  analysis  (if  the  .•ii>jiimt'iits  for  llw 
vurioiis  .sy.stcms. 

'•'  This  term,  acconliiin  to  Sukcr,  is  oftt-ii  inaccurately  ap|)li«'il.  He  would  em- 
ploy it  only  to  (lescril)e  an  uiietpiiil  aiiiouul  or  <lenree  of  tlu;  same  kind  of  refractive 
error  in  the  two  eyes.  To  <lescril»e  a  ditTernit  kind  of  icfi.ict ion  in  tlie  two  eypn 
he  prefers  the  word  anluniiii>inti. 


PRESBYOPIA  157 

be  acquired.  No  general  rule  for  the  management  of  cases  of  this 
character  can  be  given,  but  the  author  agrees  with  Duane  that  "in 
the  majority  of  cases  of  anisometropia,  even  those  in  which  the  dif- 
ference in  refraction  exceeds  2  D,  the  full  correction  can  be  apphed 
with  success."  The  patient,  however,  must  be  required  to  wear  the 
glasses  constantlj',  and  must  be  wiUing  to  bear  with  temporary  discom- 
fort while  the  ej'es  are  becoming  accustomed  to  the  lenses.  The  causes 
which  give  rise  to  discomfort  may  be  summarized  as  follows:  Diplopia 
and  asthenopia  from  the  unequal  prismatic  effect  of  the  unequallj^ 
strong  lenses;  diplopia  from  imbalance  of  the  ocular  muscles,  with  the 
full  correcting  lenses  the  double  images  being  more  manifest;  and  diffi- 
cult binocular  vision  because  the  retinal  images  of  the  two  eyes  are  of  a 
different  size,  a  cause,  however,  which  is  considered  fallacious  by  Duane. 
Exophoria  and  hyperphoria  are  often  associated  with  anisometropia; 
squint  may  be  caused  by  this  refractive  condition  and  may  be  mate- 
rially improved  bj'  the  use  of  the  correcting  lenses.  If  discomfort 
ensues,  success  may  follow  the  attempt  to  train  the  function  of  the 
more  defective  eye  by  temporarily  excluding  the  other  from  vision. 
Corrections  by  prisms  of  the  hyperphoria  is  often  of  distinct 
advantage. 

Presbyopia. — The  accommodation  diminishes  gradually  from 
early  life  onward,  and  the  near-point  recedes  farther  from  the  eye  with 
each  succeeding  year,  ^\'^len  by  this  recession  the  near-point  reaches 
a  distance  of  30  to  40  cm.  from  normal  eyes,  it  interferes  with  their  use 
at  close  range,  and  convex  lenses  are  usually  required.  Presbyopia  has 
now  begun,  and  is  a  normal  result  of  growing  old. 

Causes. — The  cause  of  presbj^opia  consists  in  loss  of  the  elasticity 
of  the  crystalline  lens,  which  is  thus  prevented  from  assuming  the  in- 
creased convexity  which  constitutes  the  essential  factor  of  accommoda- 
tion. This  increase  of  convexity,  necessary  for  seeing  near  objects, 
must  be  supplied  to  the  ej'e  bj-  a  suitable  lens. 

Presbyopia  usuallj^  begins  in  emmetropic  eyes  at  the  age  of  forty- 
five.  Unusual  visual  acuteness,  or  vigor  of  accommodation,  however, 
may  enable  a  person  to  dispense  with  glasses  for  several  years  longer. 

A  visual  acuteness  of  t  permits  its  possessor  to  see  the  same  object  dis- 

tincth'  at  30  cm.,  which  another  individuar  with  a  vision  of  only  n. 

would  have  to  hold  at  20  cm.  Patients  occasionally  postpone  the  time 
of  wearing  reading-glasses  by  holding  fine  print  in  a  bright  light,  the 
resulting  contraction  of  the  pupil  rendering  vision  more  distinct.  Pres- 
byopia is  to  be  distinguished  from  hyperopia,  which  is  often  latent  and 
confounded  with  it.  Correction  of  hyperopia  restores  the  far-point  of 
the  ej'e  to  infinity. 

Correction  of  Presbyopia. — In  the  first  stages  of  presbyopia,  while 
considerable  accommodation  still  remains,  a  weak  convex  lens  is  re- 
quired, which  enables  the  person  to  see  near  objects  by  rendering  the 
rays  less  divergent,  as  if  they  came  from  a  somewhat  greater  distance. 


158  NORMAL    AND    ABNORMAL    REFRACTION 

There  is  still  a  range  of  vision  from  the  focal  distance  of  the  glass 

to  the  near-point.     A  person  who  has  an  accommodation  of  3  I^,  and 

requires  +   1 .50  D  in  addition,  will  have  a  range  from  the  focal  distance 

1  meter 
of  the  glass     ,  en     =  66  cm.  to  his  near-point  through  the  glass;  3  D 

_  _    1  meter 

+  1.50  D  =  4.50  D;  -4  50^  =  22  cm. 

When  the  accommodation  is  entirely'  obliterated  at  seventy-five 
years  of  age,  the  convex  glass  must  be  stronger.  The  rays  are  now 
rendered  parallel,  as  if  they  came  from  an  infinite  distance,  and  the 
object  must  be  held  at  the  focus  of  the  lens.  There  is,  therefore,  no 
range  of  vision. 

The  presbyopic  glass  is  estimated  after  the  eye  has  been  rendered 
emmetropic  by  neutralizing  any  hyperopia  or  astigmatism  which  may 
be  present  (for  the  management  of  myopia  and  myopic  astigmatism  in 
these  circumstances  see  page  160). 

The  near-point  of  vision  should  be  carefully  determined  for  each 
eye  separately.  The  ability  to  read  1-meter  type  at  30  cm.  is  not 
equivalent  to  the  act  of  accommodating  for  30  cm.;  in  ortler  fairly  to 
accommodate  for  30  cm.  the  patient  should  be  able  to  read  type  which 
represents  normal  vision  at  30  cm.  (see  page  38).  If  the  accom- 
modation is  normal,  the  near-point  will  correspond  closely  with  the 
figures  given  in  the  table.  The  additional  refractive  power  required 
may  then  be  calculated.  Unduly  strong  glasses  should  not  be  employ- 
ed in  approximating  the  near-point,  lest  the  far-point  be  brought  too 
close  and  serious  discomfort  ensue.  Most  persons  read  at  an  average 
distance  of  from  33  to  40  cm.  and  in  early  presbyopia  considerable 
range  of  vision  exists  on  either  side  of  these  points;  but  at  sixty  years 
and  later  there  is  little  play— the  near-point  and  far-point  are  close 
together.  A  glass  with  which  the  patient  reads  easily  at  33  to  40  cm. 
may  then  be  ordered,  unless  visual  acuteness  is  much  diminished. 


Table  of  the  Position  of  Scar- point  at  Different  Ages. 

Age  Acconuiiodation  Point 

45 3. 50  diopters  29  cm. 

50 2.50        "  40  " 

55 1.75        "  57   " 

60 1               "  100   " 

65 0  r)0         "  L>00   " 

70 0  25         "  -100   " 

75 00         "  00 


i 


At  the  age  of  forty-five  it  is  usually  necessary  to  supply  a  -|-  1  D 
spheric  hnis  for  reading,  provided  tlu;  eye  is  ennnetropic;  if  the  (\ve  is 
hyperopic,  1  D  +  the  correction  for  the  hyperopia;  if  myopia  exists, 
-f  1  I)  is  not  recjuired.  Plus  1  D  added  t(»  the  3.50  I)  of  acconnnoda- 
tion  which  the  eye  possesses  at  foity-liM'  ycais        l.."»()  I);  this  brings 

p  to  22  cm.  (  =  22).  :iiiil  /•  to  1(10  ciii. 

\4.50  ' 


PRESBYOPIA  159 

At  fifty  years  of  age  +  2  D  is  usually  required,  with  the  same  modi- 
fications ill  case  of  hyperopia  or  myopia.  This  glass,  added  to  the 
accommodation  which  the  eye  possesses  at  50, — viz.,  2.50  D, — also 
makes  4.50  D;  this  brings  p  to  22  cm.,  but  r  is  now  only  50  cm.  distant. 
Indeed,  in  most  circumstances  a  +  1.50  or  1.75  D  is  sufficient. 

At  fifty-five  years,  +  2.50  D  is  the  glass  usually  required,  which, 
added  to  the  accommodation  (1.75).  gives  a  refractive  power  of  4.25  D; 
p  =  23.5  cm.,  r  =  40  cm.  If  stronger  lenses  than  this  are  used,  r  is 
brought  still  closer,  and  the  patient  is  forced  to  hold  the  book  near  his 

face.     If  F  =  -.  it  is  not  necessary  to  order  a  glass  stronger  than  the 
6 

one  recorded;  indeed,  usually  +  2.00  D  or  2.25  D  is  sufficient,  as  most 
persons  prefer  a  glass  which  enables  them  to  read,  resting  the  book  on 
the  lap  or  the  arm  of  a  chair.  It  is  a  great  mistake  to  order  presbj''opic 
glasses  which  are  stronger  than  the  actual  ocular  requirements  (see  also 
page  158).  These  glasses  are  for  emmetropic  eyes.  In  hyperopia  with 
presbj^opia  they  are  to  be  added  to  the  hyperopic  correction.  Visual 
discomfort  (asthenopia)  often  develops  with  the  first  attempts  to  use 
presbyopic  glasses,  owing  to  the  development  of  temporary  convergence 
— insufficiency  from  relaxation  of  accommodation.  In  these  circum- 
stances it  is  usually  necessarj^  to  reduce  the  strength  of  the  glass. 
In  the  presence  of  exophoria  prisms  base  in  may  be  added  to  the  cor- 
recting glass  and  such  combinations  are  often  productive  of  highly 
satisfactory  results  (page  615). 

It  is  of  the  utmost  importance  carefully  to  correct  astigmatism 
before  adjusting  presbyopic  glasses,  moreover  astigmatism  of  low 
degree.  Especially  is  this  true  in  the  early  years  of  presbyopia,  for 
example,  between  the  forty-fifth  and  fiftieth  years  of  life.  The  necessity 
of  search  for  inverse  astigmatism  in  these  circumstances  has  been 
referred  to  (page  151). 

As  visual  acuteness  diminishes,  a  stronger  lens  is  necessary  to  enable 
the  object  to  be  held  closer,  and  thus  subtend  a  larger  visual  angle. 
The  glass  may  be  increased  to  4,  5,  6,  or  even  D  8.  The  strong  glasses 
necessitate  the  close  approximation  of  the  object  and  a  corresponding 
diminution  in  the  field  of  vision.  The  only  rule  in  the  selection  of  such 
glasses  is  to  give  that  glass  which  affords  the  necessary  vision  with  the 
least  inconvenience.  With  very  great  diminution  of  sight,  requiring 
glasses  of  8  or  10  D,  binocular  vision  is  impossible,  and  the  better  eye 
should  be  supplied  with  a  correcting  glass,  and  the  other  excluded  from 
vision. 

With  binocular  vision,  the  reading-glasses  for  the  two  eyes  should 
be  equal  in  strength;  consequently,  when  a  different  degree  of  ame- 
tropia exists  in  the  two  eyes,  a  corresponding  difference  should  be  made 
in  the  reading-glasses.  Occasionally,  in  the  absence  of  ametropia,  or 
I  even  after  its  correction,  when  present,  there  is  an  inequahty  of  the 
accommodative  power  in  the  two  eyes.  Thus,  a  patient  of  fifty  j^ears 
may  have  2.50  D  of  accommodation  in  the  right  eye,  and  only  1.50  D 
of  accommodation  in  the  left.     Under  such  conditions  it  is  usually 


160  NORMAL    AND    .U3NOKMAL    REFRACTION 

necessary  to  order  a  corrospondin.ly  stronger  reading-glass  for  the 
o-.ro  with  tho  weaker  aceonmuxlation.  ,      r  ^i       i 

"^  Frequentlv,  n.odificati,H,s  a,o  ,vqui,o<l  in  th,.  .trcn,.h  o     he  ^l-s 
irtquiiii^Y  fr,roviinnl('  reading  nuisie.  reading  in  the       i 

w    k  a.  Llon^o,-  ,.a,„o'   Thus,  a  pa.ion,  of  fift^-five  y-vs^n-ay  n.,,^ 

'  "l^  myopia,  myopic  astigmatism,  and  nuxcl  -tj^;;-;,;;-  '■';1- 
for  the  selection  of  reading-glasses  reqmr,.  pa  la,  .  u  u>on.  a 
ti„nt«  ivith  low  degrees  of  myopia,  not  higher  than  i    '.  do  not  miu 

?fty  without  the  necessity  of  ^YTm^"^.  +  ^^^  a^^  at  sixty, 
rpouire  +  1  D  for  reading,  and  at  fifty-ti\e  +  i.ou  ia  auu  •  ' 

pSy^+  2  D,  depending  up..,.  Ins  yis..,d  acuteness^     A  niyo,.  o,^- B 
conld  dispense  with  reading-glasses  until  'h'   •'■;[  °.'  ""^    .     „,,ibiy  , 

"■■^'r;^g;;:^di--i::^:-^^^ 

f     .  .  9  f M  r,  n  loss  than  the  full  correction.      1  he  age  ha>  ht 1 1    mniu  nee 
;:  lie  ;i;n,;:^'X.ioii-,n>yopes  readily  relax  accoin^ 

TT  ''nz^rt^i  ;r'whi:r:^u  exieJuh:  f:;.-;:^!nt  to . 

l^rtaMe'dSie^'-'A  ni^o,.  of  ti  D  would  ,;.^«.;...v  n;,,ui.e    - 

:;tn72:>'];::;;rJ"^i^:;™';::^;.r';:;To,^fron,.h,:f 

,„  In  ih.we  high  grades  yisioii  is  nmch  reduced,  pi  ml  .an 
Z  :  :  -.  u  .s  Md  ,Oose' .,  the  eye,  so  ,l,a,  extension  of  the  ,ea.  in. 
distan.::  i. f  „ ,es, The  '-'he..  ,n.,nt  a,  whu  ,  a  ... 

;;-:r' ?!::;:;!  ::;:'!;n™:™:'''^x:ff;^".- 

:;--l.-':;;d,;;n:'"ts;:',::.,p^^^^^^^ 

-1  2  D  cyl.,  axis  ISO",  will  he  co.nforlahlc  w.th  a  +  1  1>  .>1-  •'-'-" 


PRESBYOPIA  161 

This  glass  produces  a  myopia  of  2  D  in  all  meridians,  and  gives  the 
patient  a  comfortable  reading  range. 

But  if  the  degree  of  mj^opia  thus  produced  is  too  great  for  comfort- 
able reading,  a  concave  spheric  lens  may  be  added  to  the  convex 
cyHnder.  Thus,  an  astigmatic  eye  corrected  by  a  —  4  D  cyl.,  axis 
180°,  would  probably  require  as  a  presbyopic  correction  —  1.50  D  sph. 
3  +  4  D  cyl.,  axis  90°.  Naturally,  the  strength  of  the  concave  sphere 
must  be  determined  by  the  patient's  age  and  visual  requirements. 

If  the  degree  of  astigmatism  is  unequal  in  the  two  eyes,  a  spheric 
lens  is  required  over  one  ej'e  to  equahze  the  refraction.     For  example: 

1.  E.  E.  -  5  D  cyl.,  axis  180°.  L.  E.  -  3  D  cyl.,  axis  180°.  This 
case  requires  a  —  2  spheric  lens  to  be  added  to  the  right  eye — viz..  —  2 
D  sph.  O  +  5  D  cyl.,  axis  90°,  to  make  its  refractive  power  equal  to 
that  of  the  left,  +  3  D  cyl.,  axis  90°. 

2.  R.  E.  -  1  D  cyl.,  axis  180°.  L.  E.  -  2.50  D  cyl.,  axis  180°. 
In  this  instance,  according  to  the  circumstances,  age,  etc.,  one  of  the 
following  combinations  may  be  ordered:  R.  E.  +  1  D  cyl.,  axis  90°; 
L.  E.  -  1.50  D  sph.  C  +  2.50  D  cyl.,  axis  90°;  or  R.  E.  +  1.50  D  sph. 
C  +  1  D  cyl.,  axis  90°;  L.  E.  +  2.50  D  cyl.,  axis  90°.  Both  of  these 
combinations  equalize  the  refraction  of  the  two  eyes,  the  first  by  pro- 
ducing in  each  eye  a  myopia  of  1  D,  the  second  a  myopia  of  2.50  D. 

In  cases  of  compound  myopic  astigmatism,  should  the  myopia 
amount  to  several  diopters,  the  reading-glass  is  secured  by  a  sufficient  re- 
duction of  the  strength  of  the  spheric  without  change  of  the  cylindric  lens. 

If,  in  lower  degrees  of  compound  myopic  astigmatism,  it  is  desirable 
to  increase  the  refraction  one  or  more  diopters,  the  procedure  is  some- 
what different.  Thus,  if  the  combination  is  —  0.50  D  sph.  O  ~  1  D 
cyl.,  axis  180°,  and  the  spheric  lens  is  omitted,  +  0.50  D  is  gained;  by 
substituting  for  the  concave  cylinder  a  convex  cylinder  with  its  axis 
reversed,  an  additional  gain  of  1  D  is  secured;  +  1  D  cyl.,  axis  90°,  in 
this  case  is  equivalent  to  adding  +  1.50  D  sph.  to  the  original  combina- 
tion. If  still  more  refractive  power  is  desirable — e.g.,  +  2  D,  +  0.50 
D  sph.  O  +  1  D  cyl.,  axis  90°,  gives  the  additional  amount. 

In  another  combination,  —  0.75  D  sph.  O  —  4  D  cyl.,  axis  180°, 
it  is  desired  to  add  +  2.50  D  for  reading.  Dropping  the  —  0.75  D 
spheric  lens,  +  0.75  D  of  refractive  power  is  obtained;  substituting  for 
the  concave  cylinder,  convex  4  D  cyl.,  axis  90°,  +  4  D  more  are  gained, 
making  +  4.75  D.  This  is  too  high,  hence  it  would  be  necessary  to 
combine  —  2.25  D  sph.  C  +  4  D  cyl.,  axis  90°,  in  order  to  obtain  the 
desired  +  2.50  D.  A  simpler  method  of  procedure  in  this  case  would 
be  to  drop  the  —  0.75  D  spheric  lens;  the  uncorrected  myopia  would 
then  furnish  0.75  D  of  the  requisite  2.50  D,  leaving  1.75  to  be  obtained. 
A  +  1.75  D  added  to  the  -  4  D  cyl.,  axis  180°,  would  make  the  proper 
combination. 

In  mixed  astigmatism,  a  combination  of  spheric  lens  and  cyhnder 
is  usually  employed,  and  b\'  using  a  concave  spheric  and  convex  cylin- 
der the  combination  necessary  to  produce  any  additional  refractive 
power  can  easily  be  found. 


162  NORMAL    AND    ABNORMAL    REFRACTION 

If  the  myopia  produced  by  the  convex  cj-hnder  alone  is  greater  than 
the  power  of  the  lens  desired,  a  concave  spheric  lens  equal  to  the  dififer- 
ence  may  be  given,  thus:  To  the  combination  —  3D  sph.  O  +  5  D 
cyl.,  axis  90°,  it  is  desirable  to  add  +  2  D.      -  3  +  2  =  -  1,  hence 

-  ID  sph.  3  +  5  D  cyl.,  axis  90°,  is  the  glass  required.     Again,  to 

-  1  D  sph.  C  +  3  D  cyl.,  axis  90°,  it  is  desirable  to  add  +  2.50  D. 

-  1  +  2.50  =  +  1.50,  hence  +  1.50  D  sph.  C  +  3  D  cyl.,  axis  90°. 
is  the  necessary  glass. 

Distortion  of  Objects  by  Cylindric  Lenses. — II  is  important,  in 
ordering  reading-glasses  containing  cylindric  lenses,  to  give  attention 
to  the  relation  of  the  axes  of  the  cylindric  lenses.  It  has  been  assumed, 
for  the  sake  of  simplicity,  that  the  axes  of  convex  cylinders  are  placed 
at  90°  and  the  axes  of  concave  cylinders  at  180°.  It  is  a  frequent  con- 
dition in  astigmatism  to  have  one  principal  meridian  inclined  15°  to 
the  right  of  the  vertical  in  one  eye,  while  the  meridian  of  the  same  re» 
fraction  in  the  other  eye  is  inclined  the  same  amount  to  the  left  of  the 
vertical.  This  produces  no  serious  disturbance  in  wearing  the  glasses 
if  they  are  properly  centered,  although  at  first  a  rectangular  figure  ap- 
pears like  a  rhombus.  In  a  little  time  the  eyes  adapt  themselves  to 
the  glasses,  and  this  appearance  is  lost. 

When  the  meridians  of  similar  refraction  are  at  greater  angles  than 
this,  especially  if  the  cylindric  lenses  are  strong,  there  is  often  incon- 
venience in  wearing  them  on  account  of  the  prismatic  deviation  and  the 
unequal  distortion  of  objects  which  cylindric  lenses  produce.  Occa- 
sionally the  axes  are  as  much  as  90°  apart,  one  at  45°  and  the  other 
at  135°,  or  one  at  90°  and  the  other  at  180°.  The  glasses  now  deviate 
rays  from  an  object  in  dirl'erent  directions,  according  as  the  eye  looks 
through  the  glasses  above  or  below  the  optical  centers,  or  to  the  right 
or  left  of  them.  Such  a  case  would  be  represented  by  +  3  D  cyl..  axis 
180°,  in  right  eye,  and  +  3  cyl.,  axis  90°,  in  left  eye.  The  difhculty 
is  not  obviated  by  ordering  a  formula  like  lh(>  following:  H.  +  3  0  cyl., 
axis  180°,  L.  +  3  D  sph.  C  -  3  D  cyl.,  axis  180°,  because  the  same 
displacement  results.  It  will  be  found  that  the  best  solution  of  this 
difficulty  is  to  ascertain  the  distance  from  the  eye  at  which  the  person 
usually  holds  tlu;  book,  and  the  relative  position  it  occuines  to  the  i\ve. 
Th(^  direction  of  the  visual  lines  may  thus  i)e  determineil.  and  the  opti- 
cal centers  of  the  glasses  should  be  so  placeil  that  the  visual  lines  will 
pass  through  them.  There  is  then  no  deviation.  Of  course,  this  ren- 
ders necessary  a  separate  pair  of  glasses  for  rcailing.  Wlien  cylindric 
len.ses  with  axes  in  unusual  directions  are  retjuircd  for  distance,  the  op- 
tical cenleis  should  bear  the  same  iclation  to  the  visual  lines  in  distant 
fixation.  These  disturbances  are  aggravated  by  removing  the  glass 
farther  fioiii  I  lie  eye,  and,  conversely,  the  trouble  diminislu^s  as  the 
glass  is  lnouglil   nearer  to  the  (\\'e.' 

'  Consult  interest iii^r  pjipcrs  in  tlie  .Vrchives  of  Ophth.nlinolony.  vol.  xviii.  by 
Dr.  .1.  A.  Lip[)inc<ift;  in  tlic  Ophlluihnic   KeconI,  vol.  i,  No.  1.  I)y  Dr.  t].  C  Savjige; 

iui'l  Df.   I{.  .1.  I'liillips.  ill  llic  Annuls  of  ()|>hliiMliniil.)ny,  vol.  ii,  p.  '.U. 


SPECTACLES    AND    THEIR    ADJUSTMENT 


163 


Bifocal  Lenses. — When  presbyopic  patients  require  two  sets  of 
glasses,  one  for  distance  and  one  for  reading  and  close  work,  it  is  the 
custom,  instead  of  providing  them  with  separate  sets  of  glasses,  pre- 
scribed according  to  the  rules  set  forth  in  the  preceding  paragraphs,  to 


Fig.  81. 


1.  2. 

-Bifocal  lenses:  1,  Solid  bifocal  lenses;  2,  cemented  bifocal  lenses. 


order  bifocal  lenses  (Fig.  81).  By  means  of  such  glasses  the  inconve- 
nience of  changing  spectacles  is  avoided,  and,  moreover,  the  patient's 
eyes  are  constantly  adapted  by  proper  lenses  to  close  and  long  ranges. 
A  spheric  lens,  suited  to  needs  of  accommodation,  ground  very  thin,  is 
cemented  on  the  lower  portion  of  the  dis- 
tance glass,  usually  upon  its  inner  side. 
The  size  of  the  additional  segment  varies. 
Generally  one  123^^  mm.  in  height  and  22 
mm.  in  length  is  sufficient.  The  shape  of 
the  supplementary  lens  varies.  Com- 
monly it  is  an  oval;  sometimes  it  is  made 
in  the  form  of  a  circle,  and  sometimes  it  is 
dome  shaped.  Another  form  of  bifocal 
lens  is  one  in  which,  for  the  usual  pres- 
byopic segment,  there  is  substituted  a  small 
lens  15  mm.  in  diameter,  made  of  flint  glass 
and  sunk  into  the  distance  lens,  which  is  made  of  crown  glass.  The 
increased  refraction  of  the  small  lens  depends  upon  the  higher  index 
of  the  flint  glass.  Its  exposed  surface  is  ground  to  the  same  curvature 
as  that  of  the  larger  lens.  Lenses  of  this  character  are  usually  known 
as  "concealed"  or  "kryptok"  bifocals.  A  "one  piece"  bifocal  lens 
may  be  ground  out  of  one  solid  piece  of  hard  crown  glass,  known  in 
the  trade  as  "Lltex  one  piece  bifocal." 


Fig.  82. — Borsch's  bifocal  lenses 


SPECTACLES  AND  THEIR  ADJUSTMENT 

After  the  refraction  of  the  eye  has  been  determined  and  the  proper 
combination  of  lenses  selected,  the  glasses  should  be  properly  ground, 
mounted  in  spectacle-frames,  and  correctly  adjusted  to  the  patient's 
eyes.  In  place  of  spectacle-frames  so  called  "eye-glasses"  are  much 
employed;  if  they  can  be  firmly  adjusted,  and  the  spherocj^indric 
combination  is  not  of  high  degree,  there  is  no  serious  objection  to  their 
use,  although  they  can  never  be  as  accurately  applied  as  spectacles. 
Patients  should  not  be  allowed  to  wear  glasses  until  the  surgeon  has 


164  NORMAL    AND    -VBNORMAL   REFRACTION 

«atisfio,l  him..lt  that  th.  fo,nu>la  for  .ho  lenses  has  been  faithfully 

If  the  glass  is  correct,  this  maneu\ti  na  „..>,, 1,1  if  it  had  been 

position  „f  th<.  obiect,  which  appears  -^^f  ^'!>,"; '^;™';    \  ,„  ,ai<l  to 
rookecU,  .h.o».h  a  p,ece  of  P  -  .1^^  ,  L'^lTn'uralizc  the  test- 

rtralle  ththereltnely,  even  if  ^^^:l^::,^lZ^ 
The  convex  lens  always  preponderates.     W '  '>  »;"  '"'^^ 

fefTlcfon,  with  its  axis  turned  to  ^c --  -gle  a.    hat  „     h    lens 

tnis,  ana  i)>  puu     ^  \Uy,.f]  Cowan  has  designed  a  useful     axis 

^'T'eoX;^tiro"f "  rnrerht  ,ens,.s  ,s  .„  betestcd  by  a 
sphni:;",::  held  .,»  l  sphenc  surface  of  ^^^^'^^XXJ^^t^ 
cylindric  lens  held  o.i  the  cyln.dr,,'  sur  ace  of  th.  ^p.    t.v 

proeecdinR  in  the  manner  just  dcs.-nbcd.     I 

The  oidical  center  is  aseertan.e,   as  '""»"-,''':,;     ,  ',„■,,„,., 

i.  seen    iust  as  the  outhnc  of  a  ligun'  is  traeed  on  a  <';'"^'^-''';;  ,'    V, 

:p:.';;;j;is  now  ,u,.,.d  ;';;::;;t:;\;j-i:t::is'f:;,;:ri:^:^;:^^i;,ch 
r'u:.^;:^";::;';;;:;;'!':';:':,::!.:'^ si w,,,,  ,h,.  ..r,  ab.,vc 


SPECTACLES    AND    THEIR    ADJUSTMENT  165 

and  below.  This  is  traced  on  the  glass  with  ink,  and  the  intersection  of 
the  two  lines  thus  traced  marks  one  extremity  of  the  axis  of  the  lens. 
In  most  lenses  the  distance  from  the  surface  to  the  center  is  so  s%ht 
that  we  may  consider  this  point  on  the  surface  as  the  center,  and  each 
lens  should  have  its  center  marked  by  a  dot  of  ink.  Strong  lenses  may 
be  centered  more  easily  by  using  the  window-bars,  while  the  glass  is 
held  close  to  them,  or  the  edge  of  a  card  or  sheet  of  paper,  which  is  laid 
on  the  desk.  Still  greater  accuracy  may  be  obtained  by  using  a  card 
on  which  two  lines  are  drawn,  crossing  each  other  at  right  angles ;  both 
principal  meridians  may  in  this  way  be  found  at  once;  the  optical  cen- 
ter then  lies  over  the  intersection  of  the  lines. 

The  spectacles  should  next  be  placed  on  the  patient,  and  the 
position  of  these  centers  in  relation  to  the  pupil  carefully  noted.  The 
patient  is  first  asked  to  look  across  the  room;  the  centers  of  the  pupils 
should  correspond  with  the  dots  on  the  glasses.  Next,  the  patient  is 
required  to  look  at  the  finger  of  the  surgeon  held  at  40  cm.  distance, 
and  it  will  be  noticed  that  the  centers  of  the  pupils  and  the  dots  no 
longer  coincide,  but  that  the  former  have  passed  to  the  inner  side  of 
the  latter.  If  the  glasses  are  for  distance  or  for  constant  wear,  the 
space  between  the  centers  of  the  lenses  should  be  the  same  as  the 
interpupillary  distance;  if  the  glasses  are  for  reading  alone,  the  distance 
between  the  centers  must  be  lessened.  The  ordinary  reading  distance 
being  40  cm,,  the  visual  lines  converge  to  this  point,  and  the  farther 
the  glasses  are  from  the  center  of  rotation,  the  nearer  the  centers 
should  come  to  each  other;  therefore  it  is  necessary  to  make  the 
distance  between  the  centers  of  the  reading-glasses  from  2  to  4  mm, 
less  as  compared  with  those  of  distance  glasses,  so  that  the  visual 
lines  may  pass  through  these  centers.  Thus:  The  center  of  the  pupil 
deviates  inward  about  1  mm.  in  fixing  at  a  point  40  cm.  distant,  as  the 
pupil  is  11  mm.  in  front  of  the  center  of  rotation;  a  glass  placed  13  mm. 
in  front  of  this  would  require  its  optical  center  to  be  1  mm.  farther 
inward  than  the  pupil — 2  mm.  in  all.  The  two  centers  should  thus  be 
4  mm.  nearer  together  in  reading-glasses  than  in  those  for  distance. 

Should  glasses  be  ground  with  badly  placed  centers, — that  is,  too 
far  apart  or  too  close  together,— the  most  unpleasant  consequences 
may  arise:  obstinate  diplopia,  severe  neuralgia,  headache,  and  tendency 
to  squint. 

The  patient  should  observe  some  distant  object  while  the  inter- 
pupillary distance  is  measured  during  distant  fixation,  but  should 
fixate  his  eyes  on  the  finger-tip  of  the  observer,  held  about  30  cm.  from 
his  eyes  while  the  measurement  is  made  during  convergence.  There 
should  be  a  variation  of  2  mm.  between  these  two  measurements.  If 
the  difference  is  greater  than  this,  there  is  a  probability  that  the 
patient  has  an  insufficiency  of  convergence,  and,  in  this  case,  the 
centers  of  convex  glasses  should  be  brought  closer  together;  those  of 
concave  glasses  placed  farther  apart.  In  order  to  ascertain  the 
amount  of  deviation  which  is  produced  by  decentering  a  spheric  lens, 
see  page  20. 


166  NORMAL    AND    .VBNORMAL    REFRACTION 

Reading-glasses  should  be  tilted  forward  and  placed  about  5  mm. 
lower  than  those  for  distance,  in  order  to  conform  with  the  depression 
of  the  visual  line  in  reading.  Spectacles  are  always  to  be  preferred;  but 
the  prejudice  of  manj-  patients  in  regard  to  spectacles  will  often  have  to 
be  respected.  The  tilting  forward  of  eye-glasses  is  rather  an  advantage 
in  reading,  and  in  myopia  the  effect  of  this  tilting  is  equivalent  to  a 
cylindric  lens  with  a  horizontal  axis.  This  fact  accounts  for  the  prefer- 
ence shown  by  some  patients  for  a  simple  concave  spheric  uncombined 
with  a  cylindric  lens,  in  spite  of  the  existence  of  a  slight  degree  of 
astigmatism. 

When  separate  glasses  are  required  for  distance  and  reading,  it  is 
often  very  inconvenient  to  make  the  change  from  one  to  the  other. 
The  two  glasses  may  be  combined  in  the  same  frame  by  making  the 
lower  half  suitable  for  reading  and  the  upper  half  for  distant  vision 
(Franklin  or  split  bifocals).  Bifocal  lenses,  as  already  described, 
constitute  a  more  suitable  arrangement  (see  page  163).  "Hook 
fronts"  are  very  convenient  for  making  a  rapid  change  from  reading  to 
distant  vision,  or  "half -hook  fronts"  may  be  employed.  Occasionally, 
for  special  purposes,  trifocal  lenses  are  manufactured — that  is.  an  upper 
segment  correcting  the  distant  vision  and  a  lower  segment  correcting 
the  close  vision  are  cemented  in  a  lens  which  corrects  the  intermediate 
vision. 


t 


CHAPTER  V 
DISEASES  OF  THE  EYELIDS 


Congenital  Anomalies. — Complete  absence  of  the  lids  (ahlepharia 
totalis),  or  their  partial  development  {ahlepharia  partialis),  is  a  rare 
anomaly.  If  the  defect  is  of  such  a  nature  that  the  lids  are  wanting 
and  the  orbit  divested  of  any  covering  for  the  globe,  the  condition  is 
designated  hgophthalmos,  a  name  which  also,  and  perhaps  more  prop- 
erly, has  been  given  to  a  contracted  state  of  the  eyelids  preventing 
their  closure,  independent  of  any  muscular  paralysis. 

Cryptophthalmos  is  a  condition  in  which  neither  eyelid  nor  con- 
junctival sac  is  present,  but  the  exterior  integument  passes  in  front  of, 
and  buries  an  eye  more  or  less 
developed. 

Cleft  eyelid  (coloboma  palpehroe) 
is  a  fissure,  in  appearance  not  un- 
like a  harelip,  which  may  be  con- 
fined to  the  upper  lid  (its  most 
common  situation),  but  which  also 
has  been  noted  in  the  lower  lid 
(when  the  upper  lid  of  the  same 
eye  is  always  also  involved),  and 
even  in  the  upper  and  lower  lids 
on  each  side.  The  center  of  the 
cleft  may  contain  an  interven- 
ing membranous  portion,  either 
movable  or  pressed  against  the 
cornea  (Fig.  83) ,  or  may  be  clear,  so  that  'the  cornea  fits  exactly  into 
it  when  the  eyes  are  directed  straight  forward. 

Coloboma  of  the  eyelids  is  most  frequently  associated  with  harelip 
and  cleft  palate;  rarely  with  facial  defects  and  other  congenital  anoma- 
lies in  the  eyeball.  The  deficiency  may  be  remedied  by  a  plastic 
operation. 

Symhlepharon,  or  a  cohesion,  ei.ther  partial  or  complete,  between 
the  eyehd  and  the  baU,  and  ankyloblepharon,  or  a  union  between  the 
margins  of  the  lids,  are  unusual  congenital  anomalies.  Sometimes 
only  the  middle  portions  of  the  lid-borders  are  attached  by  a  filamen- 
tous band,  or  the  outer  angles  of  the  lids  adhere,  and  produce  the 
defect  known  as  hlepharophimosis. 

Ectropion,  or  eversion  of  the  edges  of  the  eyelids,  is  a  rare  condition 
usually  accompanied  by  increased  size  of  the  eyeball.  Entropion,  or 
inversion  of  the  edges  of  the  eyes,  which  in  slight  degree  is  said  to  be 
normal  before  birth,  has  been  found  associated  with  distichiasis,  or 
the  development  of  supplementary  incurved  eyelashes. 

167 


Fig. 


83. — Coloboma  palpebrae  and  anoph- 
thalmoa. 


168 


DISEASES    OF   THE    EYELIDS 


In  congenital  distichiasis,  Kuhnt  has  denionstratocl  that  the  second 
row  of  lashes  consists  of  fine  hairs  springing  from  the  posterior  part  of 
the  intermarginal  area.     Meibomian  glands  are  wanting,  and  their 


Fig.  84. — Congenital  di.sti(hia>i>  (froni  a  iiaticut  in  the  Philadelphia  deneral  Ho.^pital). 

places-^are  taken  by  the  abnormal  cilia.     Occasionally  the  condition 

appears  to  be  hereditary. 

The   operations   which   are  employed  to  rectify  tliese  conditions 

when^of  pathologic  origin   (see  page  666)   are  suitable. 

Epicanthus  is  a  striking  congen- 
ital anomaly  giving  rise  to  an  appar- 
ent convergent  strabismus,  owing  to 
the  passage  of  a  fold  of  skin  from 
the  inner  end  of  the  brow  to  the  side 
of  the  nose,  covering  the  internal 
canthus,  its  free  concave  border 
stretching  outward.  Thus  the  car- 
uncle, lacrimal  punctum,  and.  in  ag- 
gravatetl  forms,  a  considerable  por- 
tion of  the  area  of  the  lids,  are 
hidden.  Epicanthus  generally  is 
bilateral  and  is  usually  associated 
with  ptosis  (Fig.  85).  The  same 
condition  in  minor  degrees  is  often 
s(>en  in  new-born  children,  and  dis- 
appears with  the  sui).se(iuent  de- 
velopment of  the  face  aiui  nose.  \ 
similar  fold  of  skin  at  the  outer  coni- 
missure  of  th(>  lids  has  been  de- 
scribed, the  so-called  external  epican- 
hei-editarv,  and  the  defect  has  been 


Fid.  sr>.  J'ipicaiithus  and  cohniMiitiil 
ptOHi.s  (from  II  patient  in  the  ('hild^en'^s 
Hospital). 


thus.     True   epicanthus    may   be 

noted  in  several  generations  (von  llippel). 

lOpieantlnis  may  be  remedied  by  excising  a  portion  of  the  redundant 
integument  from  the  bridge  of  tlie  nose,  and  stitching  together  tho 
opposed  surfaces. 

/'Jpitdr.sus  is  a  somewhat  wing-shaped  duplieature  of  conjunctiva 
whi(^h  passes  from  the  fornix  to  l»e  inserted  neai'  the  lid  border,  and  is  so 
undermined  that  a  small  prolx-  can  i)e  pa.*<.s(>d  IxMieath  it  (Schrapringer). 
This  anomaly  is  also  descrilx-d  under  thi>  name  congenital  pterygium. 


EDEMA    OF   THE    LIDS  169 

Congenital  ptosis  consists  in  a  drooping  of  the  upper  lid  over  the 
eyeball.  It  may  be  unilateral  or  bilateral,  the  latter  being  the  usual 
condition,  but  never  amounts  to  complete  closure.  In  one  variety 
there  is  an  actual  redundancy  of  the  lid  tissue;  in  the  other  the  lid  is 
thin  and  the  skin  stretched,  owing  to  imperfect  development  or  ab- 
sence of  the  levator  palpebrae.  It  may  be  caused  by  a  nuclear  and, 
rarely,  by  a  cortical  lesion.  The  hereditary  character  of  congenital 
ptosis  is  illustrated  in  H.  H.  Briggs'  noteworthy  report.  Of  128  mem- 
bers of  23  famihes  64  were  affected  with  the  ptosis — 33  males  and  30 
females  and  one  of  unknown  sex.  His  cases  conformed  to  the  Mende- 
lian  law  of  transmission. 

This  anomah"  is  often  associated  with  other  vices  of  conformation, 
especiall}'  epicanthus,  and  with  paralysis  of  the  exterior  ocular  muscles, 
especially  the  superior  rectus,  or  this  muscle  may  be  absent;  absence 
of  the  internal  rectus  (Lawford)  and  of  both  oblique  muscles  (Horles) 
has  been  recorded.  Congenital  ptosis  may  be  corrected  by  one  of  the 
operations  described  on  pages  660-665. 

Congenital  fistula  of  the  upper  lid  has  been  reported.  A  super- 
numerary eyelid,  presenting  as  a  small  growth  at  the  inner  canthus,  has 
been  described  (J.  L.  Shoemaker  and  A.  Alt). 

Edema  of  the  lids  in  general  terms  is  inflammatory  or  non-inflam- 
matory in  origin.  It  may  result  from  traumatism,  the  sting  of  an 
insect,  contact  with  certain  varieties  of  moths,  notabh'  the  brown- 
tailed  moth,  and  is  seen  with  severe  inflammations  of  the  conjunctiva, 
of  the  cornea,  the  uveal  tract,  and  especialh'  with  infections  of  the 
globe,  e.  g.,  panophthalmitis  and  in  association  with  acute  glaucoma; 
also  with  hordeolum,  acute  chalazion  and  dacryocystitis.  It  is  a  com- 
mon symptom  of  general  conditions  (renal  or  cardiac),  and  is  con- 
spicuous in  orbital  cellulitis,  tenonitis,  thrombosis  of  the  cavernous 
sinus,  disease  of  the  sinuses,  especially  of  the  ethmoid  and  antrum, 
and  sometimes  occurs  in  a  fugitive,  and  not  infrequently  recurrent, 
form.  The  last  variety  has  been  observed  with  migraine,  at  the  time 
of  the  establishment  of  menstruation,  and  spontaneously  without  ap- 
parent cause.  Some  cases  are  analogous  to  urticaria.  The  eyelid  is 
a  common  seat  of  angioneurotic  edema.  Some  types  of  edema,  non- 
traumatic in  origin,  have  been  called  essential  edemas.  According  to 
Trousseau,  the}'  are  often  arthritic  in  origin. 

A  condition  has  been  described  characterized  by  great  symmetric 
swelling  of  both  eyelids  which  present  the  usual  appearances  of  chronic 
edema,  and  to  which  Sir  Anderson  Critchett  has  given  the  name  solid 
edema  of  the  eyelids  (also  called  Elephantiasis  lymphangiodes) .  The 
affection  has  been  regarded  as  a  recurrent  lymphangitis  of  lupoid 
origin  (Morris).  Not  infrequentlj'  the  patients  have  a  history  of  re- 
peated attacks  of  er3'sipelas  (Eyre).  Persistent,  non-inflammatory 
edema  of  the  lids  is  sometimes  observed  in  children  following  measles 
(Lawson  and  Sutherland).  In  rare  instances  lid  edema  is  a  late  symp- 
tom of  syphilis. 

Erythema  of  the  lids  appears  in  the  form  of  a  hyperemia,  more  or 


170  DISEASES    OF   THE    EYELIDS 

less  diffused,  under  the  influence  of  heat  (sunburn),  traumatism,  and 
irritating  poisons,  or  as  sj'raptomatic  of  a  systemic  disturbance. 

A  passive  hyperemia,  in  which  the  superficial  veins  of  the  lids  are 
dilated  and  the  tissue  red  and  slightly  swollen. commonly  is  the  result 
of  prolonged  bandaging  of  the  eye,  and  is  seen  in  an  active  state  asso- 
ciated with  most  of  the  inflammatory  diseases  of  the  cornea  and  con- 
junctiva. 

Urticaria,  or  hives,  appears  in  the  form  of  characteristic  wheals 
associated  with  much  tinghng  and  burning  sensation. 

Treatment. — -This  consists  in  removal  of  the  cause  and  the  applica- 
tion of  a  soothing  lotion — lead-water  or  extract  of  hamamelis. 

Erysipelas  rarely  attacks  the  ej-elids  as  a  primary  affection,  but 
spreads  to  them  from  the  contiguous  facial  area.  The  chief  danger  of 
the  affection  in  this  region  is  its  liability  to  infect  the  tissues  of  the  orbit, 
producing  compression  of  the  central  vessels  of  the  retina  and  blindness 
(see  also  page  634).  It  may  spread  to  the  membranes  of  the  brain  and 
be  fatal.  The  characteristic  red,  shining,  and  later  brawny  swelling, 
and  the  formation  of  cutaneous  vesicles  and  small  abscesses,  are  the 
symptoms  which  establish  a  diagnosis. 

Abscess  of  the  lid  (phlegmon)  appears  as  a  localized  red  eleva- 
tion, and  is  often  a  severe  form  of  furuncle  or  hordeolum.  The  entire 
lid  is  hyperemic  and  the  conjunctiva  injected  and  often  edematous. 
There  are  much  pain,  headache,  and  fever.  This  affection  is  provoked 
by  injury,  exposure,  and  disease  of  the  orbit,  and  sometimes  arises  with- 
out ascertainable  cause,  especially'  in  debilitated  people  and  children. 
In  rare  instances  it  has  been  followed  by  thrombosis  of  the  orbital  veins 
and  cavernous  sinus  and  has  terminated  fatally. 

Treatment. — Pointing  should  bo  favored  by  hot,  slightly  carboUzed 
fomentations  or  compresses  soaked  in  boric  acid  solution.  As  soon  as 
fluctuation  is  detected,  or  even  earUer,  a  sharp  knife  may  be  thrust 
through  the  swelling,  parallel  to  the  muscle-fibers,  and  the  contents 
evacuated;  the  cavity  is  to  be  kept  clean  with  an  antisi'iitic  fluid. 

Furuncle  of  the  lid  is  a  localized  inflammation  of  tlu^  skin  and 
subcutaneous  tissue,  presenting  symptoms  analogous  to  abscess,  which 
goes  on  to  the  formation  of  a  central  slough  or  ''core. "  The  surround- 
ing and  overlying  tissue  may  become  gangrenous  in  subjects  of  poor 
nutrition.  The  treatment  does  not  differ  from  that  of  abscess  of  the 
lid. 

Malignant  pustule,  or  specific  anthrax,  caused  by  the  entrance  of 
th(>  Bacillus  anthrucis,  and  malignant  edema,  or  a  form  of  spreading 
gangrene,  occasionally  attack  the  eyelids.  The  former  usually  arises 
among  jx-rsons  whose  occupation  brings  them  in  contact  with  disea.sod 
animals  or  decayed  animal  matter;  the  latter  may  follow  an  injury, 
influenza,  the  exanthemata,  typhoid  fever,  whooping-cough,  and  ery- 
sipelas, but  has  also  been  described  as  an  idiopathic  affection.  Some- 
times gangrene  of  the  lids  is  metastatic  in  origin  aiul  occurs  tluring  py- 
emia. Xunia  uf  the  c i/cl ids- -\\nii  is,  a  syinMictric  gangrene  of  the  lids 
and  region  of  the  lacrimal  sac  iuus  been  dcscrilx'd.  (.langrene  of  tlio 
lids  has  been  observed  iti  diabetes. 


HORDEOLUM  171 

Treatment. — According  to  the  condition  present,  this  should  in- 
clude incision,  promotion  of  the  separation  of  the  sloughs  by  hot  com- 
presses steeped  in  boric  acid  solution,  the  use  of  the  actual  cautery 
to  check  the  destructive  tendency,  and  antiseptic  lotions. 

Usually  staphylococci  and  streptococci  are  present,  but  in  some 
of  these  gangrenous  processes  diphtheritic  bacilli  have  been  found,  and 
under  such  conditions  serum  therapy  would  be  strongly  indicated. 

Blastomycosis  of  the  Eyelids. — Blastomycotic  dermatitis,  which 
may  affect  any  portion  of  the  body,  has  involved  the  eyehds  in  about 
one-fourth  of  the  cases  thus  far  reported  (Casey  Wood).  The  affection 
begins  as  a  red  papule  and  gradually  extends  until  it  forms  a  fiat,  wart- 
like growth  with  a  red  elevated  margin.  Dry  crusts  are  apt  to  cover 
its  surface,  and  on  their  removal  a  bleeding  rough  surface  is  evident. 
Mihary  abscesses  are  seen  in  the  softened  edges,  from  which  and  from 
the  surface  of  the  growth  a  mucopurulent  discharge  exudes.  Although 
the  conjunctiva  may  be  injected,  swollen,  and  granular,  it  is  not  in- 
volved further  in  the  pathologic  process.  The  disease  is  caused  by  an 
organism  belonging  to  the  genus  oidium,  the  spores  of  the  fungus  find- 
ing entrance  owing  to  the  injury  of  the  skin  surface.  The  affection 
may  be  mistaken  for  epithelioma,  tuberculosis,  or  syphilis,  and  is  diff- 
erentiated by  the  clinical  appearances  and  by  an  examination  of  the 
secretion  from  the  miliary  abscesses  which  will  reveal  the  organ- 
isms. From  the  ocular  standpoint  the  disease  has  been  well  described 
in  this  country  by  Casey  A.  Wood,  W.  H.  Wilder,  and  Edward 
Jackson. 

Treatment. — This  should  consist  of  excision  of  the  diseased  areas, 
the  application  of  the  x-rays,  and  the  internal  administration  of  large 
doses  of  iodid  of  potassium.  Ectropion  may  occur  and  may  need  a 
plastic  operation  for  its  relief  (Wilder), 

Hordeolum,  or  stye,  consists  of  a  localized,  suppurating  inflam- 
mation of  the  connective  tissue  in  the  margin  of  the  lid  or  of  one  of  the 
glands  of  the  follicles  of  the  cilia  (Zeiss's  glands),  and  is  almost  always 
due  to  staphylococcus  infection.     This  may  remain  a  tender,  circum- 
scribed swelling,  which  becomes  invested  with  a  yellow  cap,  indicating 
suppuration,   or   it   may   cause   considerable   pain,   with   edematous 
'\  swelling  of  the  entire  lid  and  chemosis  of  the  conjunctiva.     It  is  known 
by  the  name  hordeolum  externum,  to  distinguish  it  from  a  hordeolum 
internum,  which  is  the  result  of  suppuration  of  a  Meibomian  gland. 
Some  persons  are  subject  to  a  mild  type  of  styes  which  appear  in  the 
form  of  superficial  pustules  along  the  margin  of  the  lid.     A  characteris- 
tic feature  of  hordeolum  is  its  tendency  to  recur,  and  a  single  stye, 
or  several  at  a  time,  may  appear  again  and  again  for  many  weeks  or 
months.     Recurring  hordeola  may  be  the  starting-points  of  a  chronic 
blepharitis.     Driving  in  the  cold  or  dust  and  the  strain  of  uncorrected 
i  ametropia  predispose  to  this  disorder.     Frequent  "attacks"  of  styes 
always  indicate  derangement  of  health,  and  are  especially  associated 
with  constipation  and  menstrual  irregularities.     Girls  about  the  age  of 
,  puberty  are  commonly  affected.     Recurring  styes  may  be  one  of  the 


172  DISEASES    OF   THE    EYELIDS 

manifestations  of  focal  infections  in  the  nasopharynx,  sinuses,  teeth, 
tonsils  and  intestinal  tract. 

Treatment. — A  stye  sometimes  may  l)e  al)ort('(l  l)y  the  vigorous 
application  of  a  hot  boric  acid  lotion  or  an  ointment  of  the  red  or  yellow 
oxid  of  mercury  or  applications  of  alcohol,  70  per  cent.:  the  same  end  is 
obtained  by  painting  the  inflamed  surface  with  collodion.  In  the  event 
of  failure,  suppuration  should  be  encouraged  by  repeated  apph'cations 
of  small  compresses  steeped  in  hot  water,  and  on  the  earliest  appearance 
of  pus  a  deep  incision  should  be  made  through  the  base  of  the  sweHing, 
parallel  to  the  edge  of  the  Ud.  In  persistent  and  recurring  formation 
of  styes  treatment  with  bacterial  vaccines  controlled  by  determining 
the  opsonic  index  has  achieved  excellent  results.  A  thorough  gen- 
eral examination  is  necessary  and  treatment  according  to  the  findings. 
Exanthematous  eruptions  on  the  eyelid  are  found  during  the 
course  of  the  eruptive  fevers.  The  pustules  of  small-pox.  if  they 
appear  upon  the  eyelids,  form  by  preference  at  the  commissures,  and 
in  connection  with  the  follicles  of  the  eyelashes.  '  The  subsequent 
pitting  from  loss   of   tissue   may   cause   considerable    disfigurement. 

Sometimes  a  pustule  declines  to  heal  and  forms  a  chronic  post- 
variolous  ulcer.     Vaccine  vesicles  (vaccine  blepharitis)  may  form   on  , 
the  lid-margins  from  accidental  inoculation — e.  g.,  with  the  finger-nail  , 
previously   in   contact   with   a   vaccine-pox   or    vaccine   virus.     The 
vesicles  may  develop  into  a  severe  ulcer,  and  the  bulbar  conjunctiva 
and  cornea  may  be  involved. 

Eczema  of  the  lids,  independently  of  that  variety  which  is  located 
upon  the  ciliary  margin  and  which  is  one  of  the  forms  of  blepharitis,  i 
may  appear  upon  the  general  cutaneous  surface  of  these  structures, 
usually  in  association  with  its  presence  elsewhere  on  the  face  and 
scalp,  and  is  seen  in  the  erythematous,  resiciilar,  and  pustular  varieties. 

Eczematous  eruptions  upon  the  lids  are  also  associated  with  inflam- 
mations of  the  cornea  and  conjunctiva  and  arise  under  the  influence  of 
prolonged  bandaging.  Atropin,  when  it  product's  conjunctivitis  ^see 
page  244),   may  cause  an  eczema  of  the  lids  ami  siu"rounding  face. 

Treatment. — This  depends  upon   the  character  of   the  eruption.' 
If  this  is  vesicular,  a  useful  application  is  a  ilrying  powder  composed  of 
starch,  oxid  of  zinc,  and  camphor;  if  crusts  have  fornuHl.  these  should 
be  removed  with  as  little  bleeding  as  possible  and  with  the  aid  of  ai 
alkaline  solution,  maceration  of  the  epidermis  being  avoideii,  and  ont 
of  the  following  ointments  emjiloyed:     Plain  oxitl  of  zinc,  or  etjua 
parts  of  oxid  of  zinc  and  vaselin  to  which  20  grains  (1.3  gm.)  of  calonie 
have  been  added;  or  subiiitratc  of  bismuth  in  an  ointment.      Itchini 
is  relieved  by  the  a|)plication  of  lotiu  ni\jr(i  followed  by  zinc  ointment 
If  the  disease  assumes  a  chronic  type,  some  preparation  of  tar  [pi. 
liquida  or  oil  of  cade)   may  l)e  used.     Good  results  follow   the  use  o 
aristol  ointment,  both  in  subacute  and  chronic  cases. 

As  constitutional  remedies,  (juinin,  iron,  and  str^chiiiii  aic  reconi 
mended,  and  arsenic  if  the  type  is  chronic.  l*ro|)er  n^gulation  of  die' 
an  occasional  saline  laxative,  and  good  hygiene  are  im|)()rtant  mea.surc! 


HERPES    ZOSTER    OPHTHALMICUS 


173 


Herpes  zoster  ophthalmicus  is  a  specific  infectious,  and  possibly 

contagious,  exanthem  (Van  Harlingen)  characterized  by  an  eruption 
of  vesicles,  situated  upon  inflamed  bases,  over  the  area  suppUed  by 
two  of  the  three  branches  of  the  ophthalmic,  or  first  division  of  the 
trigeminus — viz.,  the  frontal,  through  its  supra-orbital  and  supra- 
trochlear branches,  and  more  rarel}^  the  nasal  nerve. 

Neuralgic  pain,  heat,  and  redness  of  the  skin  precede  the  vesicles, 
which,  varying  in  size  from  a  pin's  head  to  a  split  pea,  appear  in  dis- 
tinct crops  or  coalesce  in  irregular  patches.  At  first  they  contain  a 
clear  yellow  fluid,  later  becoming  turbid,  until  at  the  end  of  a  week  or 
more  they  dry  up,  and  the  brown  scabs  drop  off,  leaving  beneath 
decided  and  often  disfiguring  scars. 

The  disease  may  be  mistaken  for  erysipelas,  from  which  it  should 
be  distinguished  by  the  acute  neuralgic  pain  and  the  formation  of  the 
vesicles  in  the  course  of  a  given  set  of  nerves. 

Serious  involvement  of  the  eye  itself,  by  the  formation  of  blebs 
upon  the  cornea,  (herpes  zoster  cornece)  and  by  inflammation  of  the  iris 
and  ciliary  body,  is  often  associated  with  the  disorder.  More  or  less 
conjunctivitis  is  always  present.  The  blebs  on  the  cornea  rupture 
and  form  ulcers,  which  leave  permanent  scars,  and  the  iritis  and 
cyclitis  may  pass  on  to  a  de- 
structive inflammation  of  the 
deeper  coats  of  the  eye  (ophthal- 
mitis). Deep  keratitis  {keratitis 
'profunda)  may  arise  in  connec- 
tion in  the  herpes  zoster  and  a 
form  of  parenchj-matous  keratitis 
which  precedes  by  several  daj-s 
the  cutaneous  lesions  has  been 
reported  (Terrien).  Herpetic 
eruptions  on  the  sclera  ma}' 
occur  during  the  course  of  herpes 
zoster  in  the  form  of  small  red- 
dish nodules.  Atrophy  of  the 
optic  nerves  and  paralysis  of  the 
oculomotor  and  of  the  superior 
obhque  have  followed  ophthalmic 
herpes. 

Although  the  intraocular  ten- 
sion may  be  reduced  in  this  dis- 
ease, acute  glaucoma  and  glau- 
coma secondary  to  cyclitis  are  complications  which  have  been  observed 
m  a  number  of  cases.  Weeks  attributes  elevated  intraocular  tension 
to  changes  in  the  aqueous  humor,  filtration  being  checked  on  account 
of  increase  in  albuminoid  and  globulin  substances.  In  the  author's 
experience  in  most  of  the  cases  the  rise  of  tension  has  occurred  in  con- 
nection with,  or  as  the  result  of,  cyclitis. 

Inflammation  of  the  tissues  of  the  eye  is  most  apt  to  occur  when  the 


Fig.  86. — Extensive  coalesiing  herpes  con- 
fined to  the  lower  lid. 


174  DISEASES    OF   THE    EYELIDS 

nasal  branch  is  affected,  and  the  vesicles  extend  to  the  tip  of  the  nose, 
because  from  this  branch,  through  the  lenticular  ganglion,  arise  the 
nerves  supplving  the  iris,  ciliary  body,  and  choroid.  This  is  not  an 
invariable  rule,  and  destructive  disease  of  the  eyeball  may  appear  even 
when  the  nasal  branch  is  not  involved.  A  severe  and  most  intractable 
neuralgia  often  remains  after  the  subsidence  of  the  eruption. 

Herpes  zoster  ophthalmicus  is  more  frequently  seen  among  elderly 
people  of  feeble  nutrition  than  among  adults  and  young  children,  but 
the  latter  may  be  attacked  even  in  the  absence  of  constitutional 
depression.  During  the  war  the  author  observed  an  unusual  number 
of  cases  of  herpes  zoster  among  young  adults  otherwise  in  good  health. 
It  is  possible  that  some  of  these  cases  represented  comphcations 
following  antityphoid  inoculations  (see  also  page  3oO).  Herpes 
zoster  has  been  attributed  to  an  affection  of  the  Gasseriaii  ganglion; 
in  some  instances  a  relation  between  this  disease  and  focal  infec- 
tions has  been  suggested. 

Treatment.— The    disease   runs    an    acute    course    and   tends   to 
spontaneous  recovery  in  two  or  three  weeks.    Locally,  anodynes  are 
useful-lead-water  and  laudanum,  weak  carbohc  acid  lotions    and 
preparations  of  belladonna.     Ichthyol  ointment  is  valuable.     Desic- 
cating powders  (rice-starch,  calomel,  zinc  oxid)   are  useful.     Severe 
pain  must  be   mitigated  by  opiates   and   morphin  hypodermicallv 
while  the  best  constitutional  remedies  are  full  doses  of  quinin  and 
iron,  and  later  arsenic.     Salicylate  of  sodium  and  aspirin  are  valuab  e 
and  McNab  recommends  ionic  medication,  with  sulphate  of  quinin 
by  means  of  the  positive  pole  over  the  affected  area     .  Tho  post- 
neuralgic  pain  may  be  relieved  by  croton  chloral  hydnite  in  doses  of 
5  to  10  grains  (0.324-6.5  gm.)  every  four  hours,  and  by  the  use  of  a 
mild  galvanic  current.     If  conjunctivitis,  keratitis    intis,  or  cyclit  8 
arises,  it  requires  the  treatment  directed  to  the  relief  o^/^f  ^^^f^" 
tions,  which  is  detailed  in  the  special  sections  devoted  to    heir  con- 
sideration   (see   page   270).     Should   glaucoma   arise   the   treatnunt 
must  be  modified  according  to  the  conditions,  in  some  cases  ^^b 
cyclitis  and  rise  of  tension  the  cautious  use  of  a  mydriatic  (scopolanun 
or  homatropin)  has  achieved  good  results. 

Herpes  Facialis  of  the  Lids.-Occasionally  one  or  several  groups 
of    herpes   vesicles   develop   upon   the   eyelids      Ihe   lesions   usua  y 
appear  in  the  form  of  a  small  cluster  or  a  coalescent  patch.      I  u  lid 
is  swollen,   reddened,   and   the   disease   gives  rise   to  a  »^"''^';«     "J 
itching  sensation.     The  lower  lid    is  affected    more  connnonl>    than 

''"^^menSfbest  application  is  u-hthyol  ointment,  and  under 
its  inlhiences  the  lesions  rapidly  disappear,  l^'^^.^^'^^'f^f^',^. 
junctivitis  should  be  treated  with  tl.e  usual  applications -bone   .icid 

and  argyrol.  .  i       .r  ^.,,K.w.ntr 

Blepharitis  is  the  term  applied  to  the  various  grades  of  .uKi    it. 

,„„,  ,in.u,.r  inflammation  of  the  border  of  tlie  eyehd.  which,  for  ^'l'^'^^ 

purposes,    M.av    be    gathered    int..    two    groups    -non-ulceratm     anc 


BLEPHARITIS  175 

ulcerative    hlepharitis.     The   former   maj-   be    studied   under   several 
subdmsions : 

1.  Hyperemia  of  the  Lid -border  (Hypercemia  Marginalis;  Vaso- 
motor Blepharitis). — The  margins  of  the  hds  have  an  unpleasant  slightly 
swollen,  red  appearance.  Exposure  to  cold  wind  or  any  strain  upon 
the  accommodation  causes  a  feeling  of  heat,  followed  by  burning  and 
lacrimation.  The  redness  is  caused  b}-  the  passive  congestion  of  the 
superficial  blood-vessels.  Scales  or  crusts  are  absent  or  but  sparingly 
present. 

2.  Simple  Blepharitis  (Seborrhea  of  the  Lid-border;  Blepharitis 
Ciliaris;  Squamous  Blepharitis). — This  variety  depends  upon  an  abnor- 
mal secretion  of  the  sebaceous  glands,  and  results  in  the  formation  of 
scales  and  crusts  situated  on  the  margin  of  the  lids  at  the  bases  of  the 
eyelashes,  or  adhering  to  them,  and  may  appear  in  either  a  dry  or  a 
moist  form.  Removal  of  the  hardened  sebum  exposes  the  skin,  shining, 
red,  and  occasionally  abraded.  There  is  usually  slight  conjunctivitis. 
An  accompanj'ing  seborrhea  of  the  eyebrows  and  scalp  may  be  present; 
both  lids  are  invariably  affected,  and  the  patients  complain  of  burning, 
inability  to  perform  close  work,  and  some  dread  of  light.  Occasion- 
ally, as  the  result  of  excessive  secretion  of  the  sebaceous  glands  the  lid- 
borders  are  covered  with  yellow  crusts,  which  in  appearance  have  been 
compared  to  wax. 

Exposure  to  cold  and  dust  and  the  use  of  the  eyes  quickly  increase 
the  congestion  of  the  lids.  If  the  disease  is  of  long  duration  or  is  subject 
to  frequent  relapses,  considerable  thickening  of  the  lid-margins  is  evi- 
dent, due  to  the  inflammation  surrounding  the  glands  in  the  skin  and 
tarsus.  Crust  formation  on  the  lid-margins  due  to  a  deposit  of  dried 
conjunctival  secretion  may  simulate  blepharitis.  In  these  circum- 
stances removal  of  the  scales  will  demonstrate  that  the  underlying  skin 
is  normal. 

The  second,  or  ulcerative,  form  of  blepharitis  appears  in  several 
grades  of  severity  as  a  special  localization  of — 

Eczema  Upon  the  Lid-border  (Blepharitis  Ciliaris;  Blepharitis 
Ulcerosa;  Psor ophthalmia;  Lippitudo  Ulcerosa;  Tinea  Tarsi;  Sycosis 
Tarsi  Ophthalmia  Tarsi,  etc.). 

(a)  Superficial  Form  (Marginal  Eczema) . — This  resembles  in  general 
that  variety  which  has  been  described  as  hyperemia  of  the  ciliary  mar- 
gin. The  patient  suffers  from  "weak  eyes"  and  from  frequent  attacks 
of  redness  and  soreness  of  the  borders  of  the  lids,  associated  with  the 
formation  of  crusts,  small  pustules,  and  ulcers  at  the  roots  of  the  lashes, 
without,  however,  seriously  interfering  with  their  nutrition  or  growth. 

(b)  Solitary  Form  (Blepharo-adenitis  Ciliaris,  a  name  given  byArlt) . — 
\    This  is  characterized  by  the  appearance  of  a  circumscribed  area  of 

thickening  and  redness  of  the  lid-margin,  upon  which  the  cilia  are 

I   matted  together  at  their  bases  by  the  formation  of  thick  yellow  crusts. 

I   A  single  tuft  of  this  kind  may  be  present,  or  several  on  one  lid-border; 

the  process  is  frequently  unilateral,  in  this  respect  being  unlike  the 

squamous  forms,  which  are  bilateral.     Removal  of  the  crusts  evacuates 


176  DISEASES    OF   THE    EYELIDS 

a  few  drops  of  thin  pus  from  the  surface  of  tlie  ulcer  which  lies  beneath, 
and  the  cilia,  which  usually  come  away  with  the  scab,  have  swollen 
and  thickened  roots.  Spots  of  eczema  at  the  nares  and  in  the  hair 
of  the  scalp  may  be  present  at  the  same  time,  as  well  as  disease  of  the 
lacrimal  passages. 

(c)  Pustular  Form  {Blepharitis  ('iliaris  Ulcerosa). — This  manifests 
itself  as  an  eczema  of  the  lid-margins,  in  its  worst  types  involving  the 
four  ciliary  liorders.  Thick  yellow  crusts,  which  mat  the  eyela.>^hes, 
form  along  the  palpebral  margins,  covering  deep  ulcers  which  readily 
bleed,  and  which,  often  crater  shaped,   pass  inward  to  the  tarsus. 

The  inflammatory  process,  if  unchecked,  seriously  interferes  with 
the  nutrition  of  the  lashes  and  the  edges  of  the  eyelid.  The  former  be- 
come stunted,  curled,  misplaced,  (trichiasis),  or  drop  out.  and  may  be 
entirely  absent  (madarosis,  tijlosis) .  The  latter  assume  a  rounded  sha{)e, 
are  swollen,  reddened,  thickened,  slightly  everted,  and  deprived  of  cilia 
(lippitudo,  or  "blear  eye,"  hypertrophic  blepharitis) ,  and  if  the  punctum 
lachrymale  is  displaced  or  closed,  an  overflow  of  tears  adds  to  the  ilis- 
comfort  of  the  patient. 

It  is  not  always  possible  thus  sharplj'  to  separate  the  various  types 
of  blepharitis,  as  thej^  often  shade  one  into  the  other;  nor  is  it  always 
safe  to  decide  between  those  which  arise  from  glandular  hypersecretion 
and  those  which  are  due  to  eczema.  After  the  cure  of  an  ulcerative 
variety,  small  scales  may  form  resembling  the  simple  or  sciuamoustype, 
while  the  latter  may  also  lead  to,  or  be  associated  with,  ulcerations. 

Terson  suggests  a  classification  of  affections  of  the  lid-margins  from 
the  dermatologic  standpoint.  He  would  distinguish  two  main  groups, 
the  suppurative  and  the  squamous.  The  former,  for  the  most  part, 
includes  affections  of  the  hair-follicles  and  of  the  surrounding  tissue — 
that  is  to  saj',  either  a  folliculitis  or  a  parafolliculitis.  He  regards 
ulcerative  blepharitis  as  a  process  analogous  to  sycosis.  The  squamous 
form  of  blepharitis  he  classifies  with  seborrhea. 

Etiology. — In  the  majority  of  instances  blepharitis  is  a  disease  of 
childhood,  and  is  common  near  the  age  of  puberty;  the  aggravated 
forms,  especially  those  resulting  in  chronic  changes  in  the  ciliary  mar- 
gins, are  frequently  seen  in  adults  as  the  results  of  nt^glect.  The 
malady  may  follow  in  the  wake  of  an  exanthem.  particularly  measles, 
and  finds  many  subjects  among  anemic  children  of  strumous  or 
tuberculous  habit,  with  blond  liair  and  pale  complexion.  It  is  fre- 
quently associated  with,  and  caused  by,  chronic  conjunctivitis,  even 
trachoma  and  i)hlyctenular  conjunctivitis.  The  usual  presence  of 
anietrof)ia  has  led  to  the  bi'licf  that  this  causes  blepharitis  (Hoosa). 
There  is  no  doubt  that  it  aggiavates  and  fosters  the  condition.  In 
some  families  blepharitis  is  hereditary  (Fuch.s\ 

Of  consideral)le  importance  in  the  origin  of  this  affection  are  in- 
flammations of  the  tear-sac,  stricture  of  the  nasal  duct,  and  obstructive 
diseiuse  of  the  posterior  nares,  although  it  may  be  tlifiicult,  in  individuji! 
cases,  to  decide  whether  the  Itlepharitis  has  caused  the  closure  of  the 
lacrimal    pa.ssages,    oi-    whethei-    this    h:is    developed    the    hleph.-iritis. 


BLEPHARITIS  177 

Blepharitis  is  aggravated  and  excited  by  exposure  to  wind,  dust,  and 
heat,  and  by  intemperate  habits  and  loss  of  sleep.  Finally,  some  in- 
stances appear  to  arise  from  an  abnormal  and  probably  congenital 
shortness  of  the  lids  (microblepharon) ,  resulting  in  their  insufficient 
closure  during  sleep  (Fuchs). 

Staphylococci  are  found  in  the  pustules.  McNab  has  frequently 
discovered  the  Morax-Axenfeld  bacillus  in  some  varieties  of  marginal 
blepharitis.  Stubborn  varieties  maj'  depend  upon  eczema  seborrhoi- 
cum  of  the  face;  rarely  the  trichophyton  fungus  is  found  (blepharitis 
trichophytica  of  Mibelli).  According  to  Raehlmann,  the  Demodex 
folliculorum  maj^  cause  the  disease  (blepharitis  acaria).  It  is,  however, 
a  not  uncommon  inhabitant  of  the  normal  eyelid.  Favus,  in  the  form  of 
dirty,  yellowish-white  crusts,  occasionally  appears  upon  the  eyelids, 
and  may  be  mistaken  for  blepharitis.  Microscopic  examination  of  the 
crusts  would  reveal  the  mycelium  and  the  conidia.  The  invasion  of 
the  follicles  of  the  eyelashes  by  the  Trichophyton  tonsurans,  when  the 
brow  or  beard  is  similarly  affected,  produces  an  appearance  closely 
resembling  severe  blepharitis. 

Treatment. — This  differs  with  the  type  of  the  disease,  but  in  all 
cases  the  refraction  of  the  eye  should  be  ascertained  and  any  anomalous 
condition  corrected  with  suitable  glasses.  This  will  often  cure  an  ordi- 
nary hyperemia  of  the  lid-margin,  but  if  it  is  not  sufficient,  in  addition  to 
soothing  lotions,  the  daily  use  of  a  douche  of  water  at  a  temperature  of 
68°F.,  to  which  is  added  a  little  eau  de  cologne  or  alcohol,  is  serviceable. 
Stimulating  salves  do  not  yield  good  results  in  this  variety,  but  the 
edges  of  the  lids  may  be  anointed  with  almond  oil  or  vaselin. 

In  the  cases  classified  among  the  seborrheas  all  crusts  and  scales 
should  be  removed  by  means  of  alkaline  solutions — bicarbonate  or 
biborate  of  soda,  gr.  viij  to  f  5  j  (0.52  gm.  to  30  c.c.) — or  with  a  5  per 
cent,  solution  of  chloral  (Gradle),  and  one  of  the  following  ointments 
applied  once  or  twice  dailj^:  yellow  oxid  of  mercury,  gr.  j  to  5j  (0.065 
to  3.885  gm.),  zinc  ointment,  or  the  salve  advised  by  Gradle  milk  of 
(sulphur  and  resorcin,  3  per  cent.). 

Great  care  must  be  exercised  to  remove  the  crusts  from  all  the 
ulcerated  varieties,  either  with  the  lotions  which  have  been  mentioned 
or,  after  softening,  with  forceps,  before  the  application  of  any  salve. 
A  satisfactory^  method  is  daily  gentle  scrubbing  of  the  lid-margins 
with  the  lather  of  a  good  neutral  soap.  For  this  purpose  special  soaps 
(ophthalmic  soaps)  may  be  emploj^ed.  Crusts  and  scales  may  also  be 
removed  b}^  means  of  a  cotton-wound  applicator  which  has  been  dipped 
in  peroxide  of  hydrogen.  Red  or  yellow  oxid  of  mercury  or  diluted 
citrine  ointment  or  ichthyol  (2-10  per  cent,  of  the  ammoniacal  salt) 
may  be  applied  to  the  lid-margins. 

In  chronic  cases  all  loose  cilia  should  be  extracted  with  epilating 

forceps,  and  any  deep  ulcers  should  be  touched  with  the  point  of  a  crayon 

,  of  nitrate  of  silver,  or  penciled  with  a  solution  of  the  same  drug,  or 

1  treated  with  a  mixture  of  corrosive  sublimate  in  glycerin  (1 :  100  to  1 :30 

— Despagnet).     In  severe  forms,  or  when  it  is  desirable  to  try  other 

1  12 


178  DISEASES    OF    THE    EYELIDS 

remedies,  diachylon  ointment,  15  to  24U  ^''^ii^s  (0.972-15.5  gm.)  of 
vaselin,  boric  acid  ointment,  10  to  100  grain.s  (0.05-6.5  gm.),  or  aristol 
ointment,  15  to  150  grains  (0.972-9.72  gm.),  will  be  found  useful.  Fri- 
denberg  recommends  expression  of  the  lid-margins  in  order  to  remove 
the  pathologic  secretion  from  the  glands  and  ducts.  Picric  acid  (0.8- 
per  cent.)  in  glycerin  (Fage),  and  sulphate  of  zinc,  gr.ij  to  f5  j  (0.13gni. 
to  30  c.c),  if  the  Morax-Axenfeld  bacillus  is  present,  serve  a  useful 
purpose.  Stubborn  blepharitis  has  been  successfully  treated  by 
ionic  medication,  after  the  manner  of  Wirtz.  A  I  per  cent,  solution  of 
sulphate  of  zinc  is  employed;  special  electrodes  are  required.^ 

If  the  lacrimal  passages  are  obstructed,  they  must  be  rendered 
patulous,  and  in  all  cases  the  anterior  and  posterior  nares  should  be 
explored  for  disease. 

The  constitutional  remedies  incluxle  iron,  quinin,  and,  if  struma  is 
present,  cod-liver  oil  and  lactophosphate  of  lime,  with  iodid  of  iron  or 
syrup  of  hydriodic  acid. 

Blepharitis  may  be  a  mild  affection  and  yield  readily  to  treatment ; 
or  it  may  be  stubborn,  and  require  constant  attention  and  frequent 
change  in  local  measures  to  prevent  deformities  in  the  lid-margins. 

Phthiriasis  (blepharitis  pediculosa)  occurs  when  the  pediculus 
pubis  or  crab-louse  forsakes  its  seat  of  predilection  and  finds  a  habitat 
among  the  eyelashes.  The  cilia  appear  sprinkled  with  a  fine  dark 
powder — the  eggs  of  the  parasites — which  are  usually  found  partially 
buried,  head  foremost,  in  the  hair-follicles.  There  are  some  itching 
and  redness.  The  affection  in  most  instances  has  been  observed  in 
children.  The  hce  may  be  removed  by  the  application  of  blue  oint- 
ment or  a  careful  penciling  with  a  strong  bichlorid  solution. 

Sporotrichosis  of  the  Eyelids.— This  disease  may  attack  the  eye- 
lids in  the  form  of  a  dermic  granuloma  with  swelling  of  the  preauricular, 
submaxillary,  and  cervical  lymphatic  glands  (H.  crdlVord,  ]\Iorax). 
Ulceration  of  the  lid  border  and  small  abscesses  of  the  lid  skin  may 
arise.  Syphilis,  tuberculosis,  and  blastomycosis  nuist  be  excluded  by 
cultivating  the  germ  on  maltose  agar.  The  Sporotlirix  Beurmannii  is 
the  fungus  which  usually  is  the  active  agent. 

The  treatment  consists  in  local  antisepsis  and  the  nihninistration  ot 
iodid  of  potassium. 

Syphilis  of  the  Eyelids. — Syphilitic  alTections  of  the  eyeliils  exist 
either  as  the  primary  sore  or  as  secondary  or  hereditary  manifesta- 
tions. A  chancre  usually  appears  on  the  area  includeil  by  the  litl- 
borders  and  inner  cantluis,  the  tarsal  conjunctiva  ami  tiie  culde.'^ac  anti 
therefore  includes  the  lid-hordcr  as  well  as  the  conjunctiva  (deBeck). 
The  lesion,  generally  on  one  lid,  but  in  rare  instances  bilateral,  begin.- 
as  a  pimple,  which  gradually  develops  into  a  characteristic,  somewhat 
aaui-('i-sliap<'d  ulceration,  with  ratluM-  rounded  edges  and  induiatedb:i5c 
Th(^  lymph-glands  in  front  of  the  ear  and  at  \\\c  angle  of  the  jaw  ait 
■enlarged.     (Contagion  hna  often  occinrcd  l)y  the  application  of  the  lip' 

'  For  (Ictiiils  (•(tiisult   Klin.   Moimtsbl.   f.   A^l^;(•llllnIk.,   Nov. -Dec,   190S;  alfN 
OphUuilnioHcopo,  .liiii.,  M.Ml,  p.  IS 


TUMORS    AND    HYPERTROPHIES 


179 


or  tongue  of  an  individual  suffering  from  mucous  patches  in  the  mouth 
— as,  for  instance,  in  the  act  of  kissing;  or  by  the  filthy  practice  of 
attempting  to  remove  a  foreign  body  with  the  tip  of  the  tongue.  Soiled 
fingers  have  also  carried  the  contagion. 

It  is  possible  to  mistake  the  affection  for  a  stye,  suppurating  chala- 
zion, ulcerated  tear-sac,  vaccine  ulcer,  or  small  rodent  ulcer.  In 
doubtful  lesions  a  search  for  the  Spirochceta  pallida  should  be  made; 
the  Wassermann  test  should  be  applied. 

Treatment. — Locally,  the  ulcer  may  be  dressed  with  black  or  yellow 
wash.     As  soon  as  the  diagnosis  isestabhshed,  the  ordinary  antisyph- 
ilitic  remedies  should  be  ex- 
hibited, especially  salvarsaii 
or  neosalvarsan  or  the  equiv- 
alent— arsphenamin. 

The  lesions  of  secondary 
syphilis  upon  the  eyelids  re- 
quire no  special  description. 

Among  the  later  manifes- 
tations gummas  of  the  skin  of 
the  lid,  which  break  down 
into  ulcers — so-called  tertiary 
ulcers — are  described.  The 
lesions  depicted  in  Fig.  87 
disappeared  under  the  in- 
fluence of  mercury  and  neo- 
salvarsan. 

A  papular  eruption  may 
appear  upon  the  eyelids  of 
children  the  subjects  of  he- 
reditary syphilis  shortly  after  birth.  A  form  of  blepharitis,  char- 
acterized by  sharply  ulcerated  spots,  has  been  described  as  the 
result  of  hereditary  syphihs,  and  in  subjects  of  this  disease  absence 
and  falling  out  of  the  eyelashes  have  been  noted  and  rhagades  at  the 
angles  of  the  lids  analogous  to  those  at  the  angles  of  the  mouth  (Hutch- 
inson). The  latter  condition  also  arises  during  secondary  syphilis. 
A  true  syphilitic  blepharitis  in  acquired  syphilis  has  been  recorded 
(Chaillous  and  Gu6neau). 

Tumors  and  Hypertrophies. — A  variety  of  growths,  cystic  and 
soUd,  are  found  upon  the  eyelid  and  its  border.  Among  the  latter,  warts 
or  papillomas  are  common.  These  are  benign,  except  when  in  elderly 
persons,  through  irritation,  they  may  take  on  an  epitheliomatous  nature. 
Although  they  may  be  removed  by  excision,  many  warts,  especially 
those  on  the  lids  of  old  people  are  more  satisfactorily  treated  by 
apphcations  of  radium.  In  place  of  the  ordinary  elevated  wart 
(verruca)  a  flat  variety  of  the  growth,  which  in  persons  of  mature  years 
may  be  pigmented,  often  develops  (keratosis  senilis  pigmentosus) . 
Superficial  wart-like  processes  situated  upon  the  intermarginal  area  of 
the  Hds  have  been  described  by  Birch-Hirschfeld  (acanthosis  nigricans). 


Fig. 


87. — Extensive  gumma  of  the  upper  and 
lower  lid  of  the  right  eye. 


180  DISEASES    OF    THE    EYELIDS 

Small  clear  cy.sts,  arising  from  Moll's  glands,  arc  common  along  the 
ciliary  margin,  often  giving  rise  to  considerable  irritation.  They 
should  be  punctured. 

A  reddish,  wart-like  mass  may  occur  at  the  mouth  of  a  Meibomian 
gland-duct.     It  should  be  excised. 

Angiomas  (nevi)  are  usually  congenital  growths,  and  exist  either  as 
bright-red  spots  (capillary  angiomas)  or  in  the  form  of  elevated,  bluish, 
somewhat  lobulated,  carernous  growths,  which  may  assume  large  pro- 
portions and  extend  from  the  lid  to  the  forehead  and  temple.  These 
cavernomas  become  turgid,  purplish  in  color,  and  apparently  increase 
in  size  if  the  child  cries.  They  should  be  dealt  with  early  in  their  ex- 
istence, lest  they  spread  into  the  orbit.  In  a  patient  under  the  author's 
care  a  tumor  of  this  character  extended  to  the  ajx^x  of  the  orbit  and 
involved  the  lacrimal  gland.  A  tumor  occujiying  the  upper  surface  of 
the  tarsus,  soft  in  consistence  and  bluish  in  coloi;,  has  been  noted  in  the 
eyelids  of  babies.  Clinically,  it  may  be  mistaken  for  a  cavernoma,  but 
examination  after  removal,  which  is  usually  accomplished  without 
difficulty  by  an  ordinary  dissection,  shows,  as  in  Aiiiold  KnapjVs  speci- 
men, that  it  is  composed  of  open  spaces  containing  blood,  which  are 
lined  with  large  endothelial  cells,  similar  cells  occupying  the  interven- 
ing regions.  Angiomas  arising  from  the  lymphatics  are  known  as 
lymphangiomas;  those  which  develop  from  the  blood-vessels,  as  heman- 
giomas. Nevus  pigmentosus,  and  moreover,  as  the  starting-point  of  a 
malignant  growth,  has  been  observed  on  the  eyelids. 

That  operative  interference  should  be  practised  which  promises  tlu' 
least  subsequent  deformity  to  the  lid.  If  they  aro  small,  capillary  an- 
giomas may  be  excised  or  cauterized  with  nitric  acid ;  if  of  a  larger  variety, 
their  blood-vessel  structure  may  be  destroyed  with  galvanocautery 
needles;  or  electrolysis  may  be  tried,  three  gold-plated  needles  at  tached,to 
the  negative  pole  being  inserted  in  various  positions  in  the  nevoitl  tissue, 
while  the  positive  pole  is  attached  to  some  distant  point — for  example 
the  arm.  The  seance  should  last  from  ten  minutes  to  half  an  hour, 
according  to  circumstances.  The  application  of  carbon-dioxid  snow 
has  been  efficient  in  the  treatment  of  some  angiomas.  Radium  has 
also  been  tried.  It  is  possible  sometinu's  to  excise  large  cavernous 
angiomas,  and  if  there  is  not  sufficient  skin  to  covi'r  tlie  defect  imme- 
diately, to  accomplish  this  subseciuently  by  skin-grafting.  Indeed. 
excision  by  an  ordinary  dissection,  if  it  can  be  accomplished  without 
serious  loss  of  tissue,  is  a  desirable  method  of  treatment.  In  infants, 
however,  tlie  danger  of  shock  and  hemorrliage  is  grtvit. 

Occasionally  ulceration  occurs  in  an  ;iiigioma  and  is  followed  by 
serious  hemonhage. 

A  disease  characterized  l>y  an  iiicre.is*-  in  the  volume  of  the  skin  of 
(he  lid,  which  Ix'comes  folded  and  falls  over  its  margin,  but  appears 
atrophic  and  may  l)e  transiently  red.  like  the  color  of  tlu>  cheek,  has 
been  desciibed  by  ilohmer  and  others,  and  to  it  th(>  name  augiomtgaly 
has  been  given.  It  s\inmet  ric;illy  .atTects  the  U|)per  lids,  ;ind  has  i)een 
at  I  iil)Ul<'(l  to  a  st  rudnrid  or  fmict  ional  a  noma  I  v  of  the  \;iscular  svstcni. 


XANTHELASMA 


181 


Cutaneous  horns  (fibroma;  7noUuscum  fihrosum)  occur  as  connective- 
tissue  new  growths,  either  sessile  or  pedunculated,  sometimes  asso- 
ciated with  numerous  similar  tumors  elsewhere  on  the  body.  A  cornu 
cutaneum  may  grow  from  the  margin  of  the  lid  (Fig.  88). 

Neuromas  of  the  plexiform  variety  occur  on  the  eyehds,  and  neuro- 
fibromatosis accompanied  by  optic  neuritis  has  been  observed,  and  with 
hydrophthalmos  on  the  corresponding  side.  Lipomas,  which  are  prob- 
ably extensions  from  the  orbit,  are  benign  growths  which  may  be  re- 
moved by  careful  dissection.  Ptosis 
lipomatosis,  at  one  time  attributed 
to  an  accumulation  of  fat  in  the 
connective  tissue  of  the  upper  lid, 
causing  it  to  droop  and  its  covering 
fold  to  hang  over  the  palpebral 
border,  is  due  to  relaxation  of  the 
fascia  connecting  the  skin  with  the 
tendon  of  the  levator.  Fat  hernias 
of  the  upper  lid  have  been  described 


Fig.  88. — Cornu  cutaneum  of  the  upper 
eyelid  (from  a  patient  in  the  Jefiferson  Medical 
College  Hospital). 


Fig.  89. — Neuroma  of  the  right 
upper  eyelid  and  adjacent  temporal 
region  (from  a  patient  in  the  Philadel- 
phia General  Hospital). 


b}^  Schmidt-Rimpler  as  the  result  of  a  congenital  extension  of  the 
orbital  fat  through  a  defect  in  the  orbicularis  muscle. 

Uncommon  forms  of  benign  tumors  are  adenoma  of  the  sweat-glands 
and  their  follicles,  adenoma  of  the  ^leibomian  glands  (Knappj,  papil- 
loma of  the  ciliary  border,  enchondroma  of  the  tarsus,  and  myoma  of 
the  orbicularis  (Schnaudigel).  Hypertrophy  and  ossification  of  the 
tarsus  have  been  reported  (Herbert).  An  exceedingly  rare  condition 
of  the  eyelid  is  the  so-called  sarcoid,  one  case  having  been  reported 
by  Derby  and  Verhoeff .  It  begins  as  a  redness  of  the  skin  and  sub- 
sides, leaving  one  or  more  circumscribed  infiltrated  areas,  or  it  may 
appear  in  the  form  of  a  small  nodule. 

Xanthelasma  {xanthoma)  is  a  connective-tissue  new  growth,  with 
fatty  degeneration,  usually  seen  in  the  form  of  narrow,  semicircular 
patches,  most  common  upon  the  upper  eyelids,  although  all  four  fids 
maj'  be  affected  and  more  frequent  in  women  than  in  men.  The 
patches  are  yellow  or  buff  colored,  and  on  a  level  with  the  surrounding 
skin  or  slightly  raised  above  it. 

Excision,  if  this  may  be  performed  without  producing  ectropion,  is 


182  DISEASES    OF    THE    EYELIDS 

the  simplest  method  of  treatment,  but  often  yields  unsatisfactory  re- 
sults, inasmuch  as  the  xanthelasma  reappears  in  the  region  of  the  exci- 
sion. Electrolysis  has  also  been  reconmiended  and  often  produces  good 
results.  High-frequenc}'  currents  applied  to  the  plaques  by  means  of  a 
special  electrode  are  advised  bj^  Bordier.  The  application  of  trichlor- 
acetic acid  to  small  xanthelasma  jiatches  has  been  commended, 
and  recenth'  the  application  of  radium  has  been  recommended  by 
Schindler. 

Chalazion  (Meibomian  Cyst;  Tarsal  Tumor). — This  is  a  small 
tumor  due  to  the  chronic  inflammation  of  a  Meibomian  gland  and  the 
tissue  which  surrounds  it.  The  growth  begins  by  retention  of  the 
secretion  of  the  Aleibomian  gland,  followed  by  a  peri-adenitis  and  de- 
struction of  the  tarsal  cartilage,  with  passage  of  the  tumor  toward  the 
conjunctiva  (internal  chalazion)  or  to  the  skin  (external  chalazion). 
Usually  the  process  is  &  chronic  one;  sometimes  it  assumes  an  acute 
nature  and  there  is  inflammatory  reaction  (soo  a.\so hordeohim  internum). 
A  chalazion  maj'form  in  the  excretory  duct  of  a  Meibomian  gland,  and 
then  projects  in  a  nipple-like  body  from  the  edge  of  the  lid.  Chalazia 
may  be  single  or  multiple,  and  in  severe  cases  recurrences  may  be  fre- 
quent until  a  chronic  infection  of  the  ^leibomian  glands  and  alteration 
of  the  tarsal  cartilages  take  place.  To  this  condition  Weymann  has 
given  the  name  tarsadenitis  Meihomica.  In  association  with  nasal 
ozena  an  affection  of  the  Meibomian  glands  has  been  described  in  which 
they  become  chroically  inflamed,  and  pus,  containing  the  ozena  bacil- 
lus, exudes  from  their  ducts. 

Cause. — The  cause  of  chalazia  is  not  known,  although  Deyl  and 
Hdla  maintain  that  thej^  represent  an  infectious,  bacterial  process,  the 
active  bacilli  being  identical  with  xerosis  bacilli.  It  is  possible  that 
some  form  of  micro-organism  is  responsible  for  chalazia,  which  differs 
from  the  ordinary  pus  producing  cocci  in  that  the  chronic  inflam- 
mation which  arises  is  not  pus  but  granulation  tissue.  Chalazia  may 
be  associated  with  inflanmiation  of  the  liorder  of  the  lid  and  stoppage 
of  the  duct  of  the  gland.  Individuals  affected  with  these  growths 
not  infrequently  have  ametropic  ej-es,  especially  where  there  is  a 
tendency  to  recunence  in  crops,  like  styes.  They  are  more  common 
in  adolescence  than  in  youth,  childhood,  or  in  old  age. 

Symptoms. — The  tumor  grows  slowly,  unless  it  is  of  the  acute 
type,  and  forms  a  firm  sw(>lling  attached  to  the  tarsus.  Th(>  skin  usu- 
ally is  freely  movable  over  it ;  on  the  conjunctival  surface  a  disi'oU)red, 
slightly  protruding  patch  marks  its  position.  Suppuration  may  take 
place  in  the  growth. 

A  so-called  acute  chalazion  may  be  mistaken  for  an  external  stye, 
from  which  it  is  to  be  distinguished  by  the  more  rir('uniseiih(Hl  charac- 
ter of  the  inflammation,  and  by  the  fact  that  the  stye  points  in  the  (»dge 
of  the  lid;  and  a  chronic  chalazion  for  a  sebaceous  cyst  from  which  it 
may  be  differentiated  by  the  firmness  of  its  attachment-to  the  tarsus. 
A  chalazion,  a  small  sarcoma  df  the  lid,  aiul  even  a  Ix^ginning  glamlular 
carcinoma  have  been  confounded. 


CARCINOMA  183 

Pathologic  Anatomy. — A  microscopic  examination  reveals  a  col- 
lection of  cells,  the  majority  of  which  are  of  the  small  round  variety, 
having  their  origin  in  the  acini  of  the  Meibomian  glands.  Sometimes 
large  multinuclear  (giant-)  cells  are  evident,  though  inoculation  experi- 
ments have  shown  that  these  are  not  tuberculous  in  type.  The  central 
part  of  the  growth  later  undergoes  a  mucoid  or  colloid  degeneration, 
and  a  cavity  appears,  which  is  filled  with  a  cloudy  fluid.  There  is  no 
true  capsule,  and  there  are  consequently  no  characteristics  of  a  true 
cyst.  Retention  cysts  of  the  Meibomian  glands  do  occur,  but,  as  Fuchs 
points  out,  they  are  essentially  different  from  chalazia. 

Treatment. — An  ointment — 2  grains  (0.13  gm.)  yellow  oxid  of 
mercury  to  1  dram  (3.9  gm.)  of  vaselin  or  lanolin — persistently  rubbed 
into  the  skin  over  a  chalazion  will  occasionally  cause  it  to  disappear, 
but  usually  it  is  necessarj^  to  remove  it,  according  to  the  methods 
described  on  page  660.  The  eyes  of  patients  who  suffer  from  chalazia 
are  usually  ametropic  and  suitable  glasses  should  be  adjusted. 

The  malignant  growths  which  appear  upon  the  eyelids  are  sarcoma, 
cylindroma,  carcinoma  in  the  form  of  epithelioma  or  of  rodent  ulcer,  and 
lupus. 

Sarcoma  occurs  as  a  primary  tumor  in  both  upper  and  lower  lids, 
about  109  cases  being  on  record  (up  to  1913),  and  usually  is  seen  in 
children.  In  this  country  the  recorded  cases  have  been  analyzed  by 
Wilmer,  Veasey,  Ailing,  Friedenwald,  Shumway,  and  the  author. 
In  Veasey 's  list,  the  youngest  subject  of  lid  sarcoma  was  seven  months 
old  and  the  oldest  seventy-six  j^ears.  The  author  has  removed 
sarcoma  from  the  Lid  of  a  negress  age  eightj'-one  (Fig.  90)  and  a 
hemangiosarcoma  from  the  lid  of  a  child  aged  five  months.  At  first 
the  growth  is  slightly  elastic,  and  the  skin  moves  over  it  freely,  but  the 
tendency  is  to  rapid  growth,  ulceration,  and  involvement  of 
theorbit.  The  tumor  may  attain  large  proportions.  In  apatientunder 
the  care  of  J.  Chalmers  Da  Costa  and  the  author  the  weight  of  the 
neoplasm  was  247  grams.  The  various  types  of  sarcoma  (myxosarcoma 
being  frequent)  have  been  seen  in  this  region,  both  pigmented  and  non- 
pigmented,  and  the  tumor  has  been  known  to  foUow  a  contusion. 
Cylindroma,  somewhat  aUied  to  sarcoma,  but  less  malignant,  com- 
posed, microscopically,  of  hyaline  cyHnders,  occurs  at  times  in  the 
eyelids  of  adults,  and  is  of  slow  growth. 

An  early  removal  of  the  tumor  is  urgently  indicated,  but  in  spite  of 
operation  there  may  be  recurrence  or  metastasis.  Radium  has  been 
successful  in  some  instances  (Callan,  Abbe)  and  after  the  dissection 
of  the  growth  from  its  bed  radium  treatment  is  advisable. 

Lymphomas  occur  in  the  lids  and  orbits  in  patients  suffering  from 
leukemia.  They  are  often  symmetric.  They  cannot  be  distinguished 
histological!}'  from  round-celled  sarcomas.  Lymphoma  of  the  lower 
lid  may  be  part  of  a  general  lymphomatosis  (Coats). 

Carcinoma  of  the  eyelid  often  appears  in  the  form  of  rodent  ulcer 
(Jacob's  ulcer),  which  is  a  tj'pe  of  epithelial  cancer,  being,  according  to 
F.  H.  Montgomery,  practically  a  superficial  carcinoma  of  the  tubular 


184 


DISEASES    OF   THE    EYELIDS 


variety.  It  is  characterized  by  slow  ulceration  and  non-involvement 
of  the  neighboring  h'niph-glands,  and  is  usually  seen  in  elderly  persons. 
The  growth  begins  as  a  pimple,  over  which  a  crust  appears.  Gradu- 
ally an  ulcer  forms,  which  slowly  spr(>ads  with  intlurated  and  elevated 
edges,  and,  if  unchecked,  involves  all  the  tissues  anil  destroys  the  eye- 
ball. Often  many  years  elapse  before  the  ulcer  attains  any  consitlerable 
size.  The  most  common  point  of  origin  is  the  inner  end  of  the  lower 
lid  (Fig.  91). 


k 


.<^ 


V 


Fig.   90.  —  Sarcoma  of  lid  (fnun  a  patient  in  tlic  rnivcisiiy  Hospital'). 

The  slow  growth  and  absence  of  lyniphalic  involvement,  together 
with  the  ag(!  of  the  i)ati(Mil,  suffice  lo  distinguish  rodent  ulcer  from  a 
tei'tiary  syphilitic  sore. 

It  may  be  confounded  willi  lupus,  l)ut  tlic  latter  occurs  in  >oungcr 
subjects,  is  more  inflamed  and  less  iiidmateil  ilic  ulcerations  proceed 
from  many  points,  and  are  genciailN'  associated  wiili  liii)iis  elsewhere  in 
the  body. 

Kpitliclionid  with  the  ordinary  clinical  characteristics  may  attack 
the  eyelid,  and  is  one  of  the  coiiunonest  tumors  of  this  rt>gion.  It 
usually  begins  at  the  lid  niaigin,  and  is  more  fretnient  on  the  lower 
ilian   on   the  iippei-  lid.      ll    not    inl  re(|iient  ly   is  situated  at    the  outer 


CARCINOMA 


185 


commissure  and  involves  both  lids  (Fig.  92).     Microscopically,  it  con- 
sists chiefly  of  a  downgrowth  of  the  interpapillary  processes  of  the  rete. 


Fig.  91. — Destruction  of  eyeball  and  orbital  tissues  by  a  rodent  ulcer:  five  years  be- 
tween the  two  stages  (from  a  patient  in  the  Philadelphia  General  Hospital). 

The  epithelial  plugs  often  contain  "cell-nests."  According  to  Gins- 
berg, a  certain  number  of  growths  recorded  as  epitheliomas  are  really 
endotheliomas.  Glandular  carcinoma, 
having  its  point  of  origin  either  in  the 
Meibomian  or  in  Krause  's  glands,  ma}' 
also  occur  in  this  region. 

Treatment.  —  Certain  local  rem- 
edies, as  aristol,  chlorate  of  potas- 
sium, and  injections  of  pyoktanin, 
have  been  recommended.  If  the 
disease  is  advanced,  Canquoin's  paste, 
ehloracetic  acid,  scraping,  and  the 
actual  cautery  have  been  employed 
to  check  the  ulceration,  but  these 
procedures  are  far  inferior  in  their 
effects  to  the  action  of  the  x-rays  and 
of  radium. 

At  the  author 's  request  Dr.  Henr\^ 
Pancoast,  Professor  of  Rontgenology 
in  the  University  of  Pennsylvania, 
has  prepared  the  following  directions,  which  will  be  found  useful 


Fig.  92. — Epithelioma  of  the  eye- 
lid (from  a  patient  in  the  Jefferson 
Medical  College  Hospital). 


186 


DISEASES    OF   THE    EYELIDS 


An  important  consideration  in  x-ray  applications  in  the  neighbor- 
hood of  the  orbit  is  the  possible  injury  to  the  eye  that  may  result  from 
the  exposures.  Ulceration  antl  opacity  of  the  cornea,  severe  conjunc- 
tivitis, edema  of  the  conjunctiva  and  lids,  and  optic  neuritis  have  been 
noted.     The  eye  should  always  be  carefulh'  protected. 

Epitheliomas  involving;  the  lids  are  frequently  troublesome  and 
obstinate,  because  there  is  a  tendency  to  allow  too  little  exposure  to  the 
rays  lest  the  eye  be  damaged,  or  sufficient  treatment  cannot  be  given 
on  account  of  the  danger  of  injuring  the  ocular  coats.  If  the  growth 
overUes  the  ej'cball,  cocain  ma}^  be  introduced,  and  then  a  hard-rubber, 
ivory,  or  metal  eye  spatula  may  be  inserted  under  the  lid.  All  the  sur- 
rounding  healthy  parts  should  be  covered  by  an  impenetrable  protect 


Fig.  93. — Epithelioma  of  eyelid  encroaching  on  eyeball  (from  a  patient  in  the  Phila- 
delphia General  Hospital). 


ive.  The  quality  and  quantity  of  rays  used  are  most  important. 
The  tube  should  be  soft,  such  a  one  which  has  a  resistance  e(jual  to  1  or 
1,^  inches  of  spark-gap.  and  it  should  be  placed  as  near  to  the  area  as 
possible.  A  current  of  1  to  3  milliamperes  may  be  used  in  the  second- 
ary. With  the  aid  of  a  mechanical  spring-interrupter  the  average 
duration  of  each  exposure  should  be  from  five  to  ten  miinites.  On 
account  of  the  latency  of  x-ray  effects  many  operators  advise  giving  the 
exposures  in  series.  Four  or  more  applications  are  made  on  successive 
days,  and  then  an  interval  of  several  days  follows  before  the  next  set  of 
exposures  is  given.  With  such  a  technic  the  neces.sjiry  lumiber  of 
appHcatioiis  does  not  entail  much  dniigcr  to  the  eve.  .At  the  same  time 
it.  sliould  be  lioinc  in  mind  that  pn'Iiniin;u\'  parti.al  or  (•oinpl('t(>  excision 
should  be  pcrfoiincd  when  it  is  not  inconsistent  with  liood  cosmetic 
results. 

Although,  according  to  Pancoast,  excellent  results  hav(^  been  ob- 
tained in  many  instances  in  the  tr(>atment  of  epitheliomas  of  the  eye- 
lids by  the  use  of  Itontgen  rays,  the  results  from  radium  he  believes 
are  preferable  and  more  certain,  and  tli(>  l!itl(>r  agiMit  can  usually  be 


LEPRA  187 

employed  to  better  advantage  and  with  greater  safety  to  the  eye. 
The  reaction  to  radium  in  the  unprotected  bulbar  conjunctiva  is  very 
severe  and  the  eye  should,  therefore,  be  adequately  protected  against 
the  less  penetrating  beta  rays.  This  can  readily  be  accomplished 
when  the  apphcation  is  made  near  the  palpebral  margin  by  inserting 
a  piece  of  metal  such  as  a  Snellen  clamp  between  the  lid  and  the  eye, 
after  cocainization.  Such  treatment  results  in  a  minimum  loss  of 
tissue,  and  any  resulting  deformity  can  be  corrected  subsequently 
if  necessary.  Papillomas  may  be  removed  in  the  same  manner.  The 
exact  dosage  of  the  radium  depends  upon  the  conditions  present.  In 
small  superficial  epitheliomas  of  the  lid  margin,  about  25  milligrams 
of  the  radium  element  for  half  an  hour  is  usually  sufficient;  the  apphca- 
tion may  be  repeated  in  three  weeks  if  necessary. 

In  recent  years  "electric  desiccation"  has  been  successfully  employed 
in  the  treatment  of  lid  carcinomas  and  also  of  epibulbar  growths 
and  has  been  highly  commended  and  elaborately  practised  by  W.  L. 
Clark.  By  "desiccation,"  according  to  Burton  Chance  who  also 
recommends  this  procedure,  "is  meant  the  dehydration  of  tissues  by 
means  of  heat  applied  in  the  form  of  an  electric  'flame'  produced  by  a 
high  frequency  current  whereby  the  vitality  of  the  tissue  cells  is 
destroyed."  The  heat  is  produced  by  a  monopolar  electric  current 
of  high  tension,  generated  best  by  a  static  machine  and  transformed  by 
suitable  appliances.  The  heat  flame,  which  must  not  be  so  intense 
as  to  char  the  tissues,  flows  from  the  point  of  a  fine  steel  needle. 
"Desiccation"  must  not  be  confused  with  "fulgm-ation, "  which  consists 
in  the  indirect  destruction  of  tissue  by  the  application  of  a  current 
generated  by  an  induction  coil  or  transformer. 

Lupus  vulgaris  is  a  cellular  new  growth  composed  of  variously 
shaped,  reddish  tubercles,  which  usually  terminate  in  ulceration  and 
extensive  cicatrization.  As  this  disease  commonly  appears  on  the  face, 
it  may  also  involve  the  eyelids. 

The  process  begins  in  youth,  often  before  puberty,  and  is  slow  in 
its  course.  The  ulcers  are  apt  to  start  from  a  number  of  points  which 
coalesce;  their  edges  are  soft,  and  the  discharge  is  offensive.  Syphilitic 
ulcers,  on  the  other  hand,  are  deeper,  more  excavated,  with  harder 
margins,  and  their  course  is  more  rapid.  Tuberculosis  of  the  lid  and 
tarsus  is  usualh^  secondary  to  conjunctival  tuberculosis;  rarely  it  is 
primary  and  may  simulate  the  clinical  picture  of  chalazion  (von 
Hippel). 

Treatment. — Local  application  of  caustic  paste,  erasion  with  a 
curet  and  the  actual  cautery  have  been  employed,  and  injections  of 
tuberculin  have  been  recommended. 

Lepra.— Leprosy  attacks  the  eyelids  very  frequently.  According 
to  Lopez,  two-thirds  of  those  affected  with  this  disease  suffer  from  le- 
sions in  this  region.  These  consist  of  anesthetic  patches  of  color  shght- 
ly  different  from  that  of  the  surrounding  integument,  tubercles,  loss  of 
the  eyelashes  and  eyebrows,  and  ectropion  and  entropion,  the  former 
occurring  with  extraordinary  frequency. 


188 


DISEASES    OF    THE    EYELIDS 


Xeroderma  Pigmentosum. — According  to  Greeff.  the  ocular 
afifections  in  this  disease  are  found  both  on  the  skin  of  the  hds  and  the 
mucous  membrane  of  the  eye;  more  rarely  on  the  cornea.  The  earhest 
evidences  of  the  disease  appear  on  the  face,  and  particularly  on  the  lids. 
After  certain  irritative  symptoms,  an  atrophic  process  develops  with 
areas  of  pigmentation,  and  even  in  the  earh-  stage  of  the  disease  the 
cilia  fall  out  and  disappear.  Later,  elevations  of  a  wartj'  appearance 
develop,  the  epithelial  processes  of  which  extend  inward  and  become 
true  carcinomas.  The  disease  may  occur  in  childhood  as  well  as  in 
adult  age,  and  it  is  interesting  that  even  in  youth  carcinoma  may  de- 
velop. L.  W.  Dean  has  reported  favorable  results  from  the  use  of 
cocoa  butter  locally  and  injections  of  autoserum.  Thorium  has  been 
tried.  The  carcinomatous  tumors  may  be  removed  if  they  are  not 
too  numerous. 

Elephantiasis  arabum,  a  chronic  hypertrophic  disease  of  the 
skin  and  subcutaneous  tissue,  has  appeared  in  the  upper  eyelid  in 
consequence  of  an  injury,  but  may  also  be  congenital.  .According  to 
Cirincione,  a  distinguishing  feature  of  true  elephantiasis  of  the  litis  is 
that  at  least  two  lids  are  involved,  and  generally  four  of  them.  Re- 
peated attacks  of  erysipelas  have  etiologic  importance.  Elephantiasis 
telangiectodes,  or  that  disease  which  consists  in  a  hj-pertrophy  of  the 

skin  and  connective  tissue,  together  with 
fatty  tissue  and  distended  vessels,  occurs 
in  the  ujiper  eyelid  as  a  congenital 
affection. 

Tarsitis,  or  inflammation  of  the 
tarsus,  is  usually  syphilitic  in  origin,  and 
presents  great  thickening  of  the  tarsus, 
owing  to  diffuse  gunnnatous  infiltration 
(Fig.  94).  It  may  also  be  due  to  tuber- 
culosis and  to  trachoma.  As  a  rule,  it 
is  chionic  in  course;  an  acute  form  has 
been  descrilx'd.  The  disease  may  re- 
semble a  chronic  marginal  blepharitis, 
witli  the  fornuition  of  crusts  and  ulcers 
at  the  moutiis  of  the  hair-follicles,  but 
differs  from  the  latter  coiuhtion  by  the 
picsence  of  consideral)le  thickening  an^l 
induration  of  the  tarsus.  Alt(>ration  of 
the  tarsus,  owing  to  cliionic  infection  of  the  Meil)omian  glanils,  may 
arise,  and  lias  been  i-efericd  to.  Suppurative  tarsitis  has  occurred; 
the  author  has  iccorded  one  case  of  tliis  character  apparently  ihie  to 
influenza.  An  ulcci;iti\-e  \;iiiel>'  due  to  sxphilis  lias  l)een  desci-ibed 
(Morax). 

Treatment.  It  syphilitie.  t;nsitis  is  ;inienalile  to  the  ortliiuiry 
remedies;  if  not,  much  the  s;ime  treatment  desciilu'd  in  connection  with 
chronic  blepharitis  is  applicable,  especially  the  use  of  resolvent  oint- 
ments. 


I'ui.  t)t.  From  a  ph<>tonrui)h  of 
a  patient  with  syphilitic  tarsitis 
under  the  eare  of  Dr.  Raii<hill,  in 
the  Children's  Hospital. 


BLEPHAROSPASM  189 

Blepharospasm,  or  an  involuntary  contraction  of  a  portion  or  the 
whole  of  the  orbicularis  palpebrarum,  appears  as  either  a  clonic  or  a 
tonic  cramp. 

The  former  variety  may  consist  merely  in  a  twitching  of  a  few 
fibers  of  the  muscle,  most  commonly  in  the  lower  lid,  very  annoying, 
and  often  the  cause  of  undue  alarm.  It  arises  from  the  strain  of  ame- 
tropia, prolonged  eye  use,  and  deficient  amplitude  of  accommodation. 
It  also  occurs  in  a  severe  and  intractable  form,  and  occasions  much  dis- 
comfort and  conjunctival  irritation. 

The  treatment  comprises  the  prescription  of  glasses  and  a  general 
tonic.  In  stubborn  cases  fluidextract  of  gelsemium  will  occasionally 
afford  relief.  Conium  internally,  and  the  extract  locally,  have  been 
recommended.  In  recent  times  hypodermic  injections  of  80  per  cent, 
alcohol  at  the  emergence  of  the  facial  nerve  have  been  tried  and  satis- 
factory results  have  been  reported. 

Children  are  often  affected,  especially  during  their  early  school 
years,  with  undue  winking  of  the  eyelids,  associated  at  times  with 
jerky  movements  of  the  facial  and  other  muscles.  This  form  of  nerv- 
ous disorder  was  designated  by  Weir  Mitchell  habit  chorea.^  Almost 
invariably,  blepharitis,  folhcular  and  phlyctenular  conjunctivitis,  and 
errors  of  refraction  and  heterophoria  are  exciting  causes.  Long-con- 
tinued blepharospasm,  especially  in  children  with  phlyctenular  con- 
junctivitis, may  give  rise  to  lid-edema,  due  to  pressure  of  the  contracted 
orbicularis  on  the  palpebral  veins.  Suitable  glasses  and  appropriate 
local  remecUes,  together  with  the  exhibition  of  Fowler's  solution,  will 
usually  bring  about  a  cure. 

Tonic  cramp  of  the  orbicularis  follows  the  introduction  of  foreign 
bodies  into  the  eye,  the  presence  of  inflammations  of  the  cornea  and  con- 
junctiva, and  fissures  at  the  angles  of  the  hds,  and  depends  upon  irri- 
tation of  the  peripheral  trigeminal  filaments. 

More  rarely  a  persistent  lid  cramp  occurs,  without  obvious  cause, 
and  is  unrelieved  for  weeks  and  even  months.  When  the  eyes  are 
finally  opened,  there  may  be  temporary  blindness,  without  correspond- 
ing ophthalmoscopic  changes;  or  permanent  loss  of  vision,  with  gross 
lesions  in  the  eye-ground. 

Blepharospasm,  both  clonic  and  tonic,  usually  the  latter,  is  not  an 
uncommon  manifestation  in  the  subjects  of  hysteria  (see  also  pp.  555, 
556)  as  is  also  spastic  ptosis,  which  depends  upon  a  cramp  or  spasm  of 
the  palpebral  portion  of  the  orbicularis.  Tonic  blepharospasm  was 
frequently  noted  among  the  so-called  "shell-shock"  cases  during  the 
war. 

The  treatment  demands  the  removal  of  any  peripherally  exciting 
cause — fissure,  foreign  bodies,  phlyctenules,  etc.  Hypodermic  injec- 
tions of  morphin  have  been  used  to  control  the  trigeminal  irritation, 
and  in  severe  cases  section  of  the  supra-orbital  nerve  has  been  performed. 
Conium  and  gelsemium  in  the  form  of  the  fluidextract  may  be  tried. 
They  should  be  pushed  to  the  point  of  tolerance.  The  hypodermic  use 
^  Gowers  gave  the  name  "habit  spasm"  to  this  affection. 


190  DISEASES    OF   THE    EYELIDS 

of  alcohol  has  been  referred  to.     Hysterical  blepharospasm  is  curable 

by  "suggestion"  and  the  general  measure  suited  to  this  psychosis. 

Paralysis  of  the  orbicularis,  chiefly  noticeable  when  the  patient 
endeavors  to  close  the  lids,  which  are  then  only  partly  approximated, 
is  due  to  an  aTection  of  the  facial  nerve.  Epiphora  is  apt  to  be  marked 
because  of  the  sagging  of  the  inner  half  of  the  lid  (paralytic  ectropion). 
There  is  always  danger  of  exposure  keratitis  (see  also  p.  284).  Facial 
palsy  and  hence  paralysis  of  the  orbicularis  of  interosseous  or  external 
origin  (Bell's  palsy)  may  be  due  to  exposure  to  cold,  to  aural  diseases, 
especiall}'-  suppuration  of  the  middle  ear,  to  injury,  to  fracture  of  the 
skull,  and  to  operation  on  the  parotid  and  middle  ear.  The  author  has 
observed  bilateral  paralysis  of  the  orbicularis  following  fracture  of  the 
skull  with  only  slight  involvement  of  the  lower  facial  area.  In  some 
cases  a  toxic  neuritis  or  perineuritis  caused,  for  instance,  bj'  syphilis 
or  acute  specific  infectious  processes  is  responsible  for  paralysis  of  the 
orbicularis.     More  rareh'  the  lesion  has  a  central  situation. 

Treatment. — After  removal  of  the  cause  this  is  largely  symptomatic 
and  may  include  electricity.  The  eye  should  be  covered  to  avoid 
exposure  keratitis. 

Ptosis  (blepharoptosis)  is  that  condition  in  which  the  upper  lid 
droops  cntireh^  or  partially  over  the  ej^eball,  and  cannot  be  voluntarily 
raised.  It  is  either  congenital  (see  page  169)  or  acquired  by  reason 
of  the  development  of  fatty  or  other  accumulations  in  the  connective 
tissue  of  the  lid  (pseudoptosis,  see  page  181),  or  it  arises  from  paralysis 
of  the  oculomotor  nerve,  and  in  rare  instances  from  lesion  of  its  cortical 
center  (paralytic  ptosis).  Slight  ptosis  may  follow  paralysis  of  the 
sympathetic  nerve,  because  this  supplies  the  superior  tarsal  muscle 
of  Miiller  (see  also  page  396).  Ptosis  also  occurs  as  the  result  of  in- 
jury of  the  levator.  In  some  cases  of  unilateral  congenital  ptosis, 
usually  on  the  left  side,  while  the  eyelid  cannot  be  voluntarily  raised,  it 
is  elevated  when  the  jaw  is  moved  during  eating  (contraction  of  the 
levator  in  association  with  the  external  pterygoid  or  '^jau'-wiiiking") 
(see  also  Ocular  Palsies). 

It  is  convenient  to  make  reference  in  this  place  to  other  associations 

in  muscle  action.     Thus,  there  may  be  contraction  of  the  orbicularis 

.  with  movements  of  the  jaw,  contraction  of  the  levator  with  abduction 

and  adduction,  and,  as  reported  by  Zentmayer,  contraction  of  the 

frontalis  with  abduction. 

Treatment.  —Tile  medicinal  treatment  of  ptosis  calls  for  the  exhibi- 
tion of  those  remedies  which  control  the  supposed  cause  i)f  the  palsy — 
mercury  and  iodids  in  syphilis,  salicylic  acid  in  rheumatism. 

The  surgical  treatment  will  be  found  on  page  600. 

Blepharochalasis,  or  relaxation  of  the  skin  of  the  lid,  due  to 
atrophy  oi  the  inteicellular  tissue,  lias  been  described  by  Fuclis  and 
other  writers.  The  skni  of  the  lid  is  thin,  much  wrinkled,  ami  its  super- 
ficial V(-'ins  are  dilated.  The  condition  may  be  remetlied  by  excising 
appropriate  portions  of  the  relaxed  tissue  and  uniting  the  cut  edges 
witli  sutures. 


SYMBLEPHARON 


191 


Lagophthalmos,  or  an  inability  to  close  the  eyelids  completely 
(total  lagophthalmos  is  rare)  is  either  paralytic  or  non-paralytic,  and 
usually  results  from  paralysis  of  the  facial  nerve,  as  already  described, 
(page  190),  but  also  occurs  as  the  result  of  loss  of  lid  tissue,  in  ectropion, 
in  tumors  of  the  orbit,  exophthalmic  goiter,  staphyloma  and  as  a 
congenital  defect  (see  page  167).  Failure  of  the  Uds  to  come  in 
contact  with  the  globe  at  the  outer  canthus  has  been  recorded  as  a 
congenital  condition.  Widening  of  the  palpebral  fissure  and  drawing 
up  of  the  upper  Hd  due  to  spasm  of  the  superior  tarsal  muscle  of  MiiUer, 
such,  for  instance,  as  is  produced  by  the  instillation  of  cocain,  must 
not  be  mistaken  for  lagophthalmos. 


Fig.  95. 


-Ptosis  with  edema  of  tissues,  the  result  of  laceration  of  the  lid  and  insertion 
of  the  levator. 


The  chief  danger  of  the  affection  is  ulceration  of  the  cornea  from 
exposure,  rendered  all  the  more  certain  should  disease  of  the  trigeminus 
also  exist. 

Treatment. — In  paralytic  lagophthalmos  the  primary  cause  of  the 
affection  must  be  treated:  in  the  non-paralytic  varieties,  and  in  any 
form  in  which  the  vitaUty  of  the  cornea  is  threatened  by  its  exposure, 
the   operation   of  tarsorrhaphy  may  be   employed    (see    page   665). 

Symblepharon,^  or  a  cohesion  between  the  ej'-elid  and  the  ball, 
may  be  complete  or  partial,  acquired  or  congenital  (see  page  167). 
The  most  usual  causes  are  injuries,  especially  burns  with  acids,  lime, 
or  molten  metal  (see  page  257) .     Symblepharon  also  follows  diphtheritic 

^  Symblepharon  really  belongs  to  diseases  of  the  conjunctiva,   but  is  conve- 
niently inserted  in  this  place. 


192 


DISEASES    OF   THE    EYELIDS 


Fig.  96.  —  .Synil)lcpharon,  the  sequel  of 
purulent  conjunctivitis  (from  a  patient  in  the 
Phil:ulc!i)hia  Ciciieral  Hospital). 


conjunctivitis,  trachoma,  pcnijihifius,  and  occasionally  purulent 
conjunctivitis;  but  the  shortening;  of  the  conjunctival  sulcus,  which 
occurs  by  a  species  of  dryinji;  of  the  conjunctiva,  i)resently  to  be  de- 
scribed, must  not  be  confounded  with  a  true  symblepharon.  The 
attachment  may  be  merel}'  slight  bands  between  the  conjunctival 
surface  of  the  lid  and  ball,  or,  in  the  more  complete  cases,  the  cornea 

may  also  be  involved  in  the 
cicatricial  union,  and  vision  be 
seriously  disturbed.  The  lower 
lifl  is  most  usually  involved  in 
the  process;  the  upper  may 
also  participate  (Fiu^  !•(>). 

Ankyloblepharon,  or  that 

condition  in  which  the  borders 

of  the  two  lids  have  grown  to- 

g(>ther,  may  be  congenital  or  ac- 

(luired,  and,  like  the  preceding 

affection,  partial  or  complete. 

The    same    causes    which 

originate     symblepharon     are 

active,  and  varieties  have  been 

described  in  which   the  union 

takes  place  not  by  a  growing 

together   of   the   lids,  but  by 

the  organization  of  a  incMnbrane,  the  result  of  croupous  conjunctivitis. 

Blepharophimosis  is  the  nani(>  given  to  that  condition  which 

arises  through  a  contraction  of  the  outer  commissure  of  the  lids,  and 

results  in  shortening  of  the  palpebral  fissure. 

It  is  commonl}^  seen  in  cases  of  long-standing  conjunctivitis  with 
irritating  secretions;  for  instance,  in  chronic  conjunctivitis  and  in  some 
of  the  forms  of  trachoma. 

Treatment. — After  an  injuiy,  or  during  the  course  of  a  local  dis- 
ease, likely  to  result  in  one  of  these  comjjlications,  scrupulous  care  nuist 
be  exercised  to  avoid  it.  The  formation  of  granulation  tissue  may  be 
broken  up  with  a  probe,  and  it  has  been  advised  to  place  a  piece  of  gold- 
beater's skin  or  tlu;  thin  skin  from  the  inner  surface  of  an  (>gg-shell 
(Coover)  between  the  lid  and  the  ball  to  prevent  adlu'sions. 

The  surgical  t  real  luent  of  these  affections  is  described  on  page  OS-t. 
Trichiasis;  Distich iasis. — Trichidsis  is  that  alTection  in  which  the 
lashes  are  misplaced  and  turn  inward  against  the  eyeball;  (lisiichiasis  is 
that  condition  in  which  incui'ved  i-ows  of  supplementary  cilia  ;ire  de- 
veloped from  the  inlermarginal  pait,  close  to  the  o|)ening  of  the  tarsal 
glands. 

"^riie  most  usual  c;uises  of  t  rich  iasis  are  chionic  inll.annnal  inns  of  the 
lid-l)oi-ders  .-ind  conjunctiva     lilcphaiit  is  ;in(l  t  raclionia. '      Dist  ichiasis. 

'  K.icliiiiianii  liclicvcs  tliat  triclii.'isis  liairs,  itr  "false  cilia,"  art' (icvclopcd  from 
the  cpitiiclial  (-ovcriiiK  of  the  litl-inarKiit  in  (*oiKse(|UCitoe  uf  iiiaixiiial  liIo))liuritit>, 
tlic  result  of  granular  eonjunotivitiH. 


ECTROPION 


193 


in  rare  instances,  is  congenital,  or  develops  about  the  age  of  puberty. 
The  cilia  rubbing  against  the  cornea  produce  constant  irritation  and 
may -lead  to  ulceration. 

Treatment.— If  not  too  numerous,  the  lashes  having  a  faulty  direc- 
tion should  be  removed  with  cilium  forceps,  and  when  they  grow  again, 
the  procedure  repeated;  their  reappearance  may  sometimes  be  pre- 
vented by  destruction  of  the  hair-follicles  by  galvanopuncture.  Other 
operations  consist  of  strangulation  of  the  roots  of  the  incurved  lashes 
by  a  subcutaneous  ligature,  excision,  and  the  various  modifications  of 
a  single  and. double  transplantation  of  the  entire  ciliarj-  border  (see 
chapter  on  Operations). 

Alopecia  of  the  eyelids,  the  loss  of  the  lashes  depending  upon  the 
fact  that  the  patient,  usuall}^  a  hysteric  girl,  systematically  pulls  -out 
the  cilia,  has  been  described  by  H.  Gifford.  The  author  has  seen 
several  cases  of  this  character.  Sudden  turning  gray  of  the  eyelashes 
has  been  recorded  b^-  Hirschberg  after  phlj^ctenular  disease,  and  has 
occurred  in  sympathetic  ophthalmia  and  iridocyclitis.  Premature 
graytiess  of  the  cilia,  sometimes  temporary,  has  also  been  reported. 

Entropion,  or  inversion  of  the  lid,  like  trichiasis,  is  most  com- 
monly caused  in  an  organic  form  by  trachoma,  and  also  follows  essential 
shrinking  of  the  conjunctiva  and  diphtheritic  conjunctivitis.  Entro- 
pion and  trichiasis  are  often  associated. 


Fig.  97. — Ectropion  of  the  upper  lid, 
the  result  of  an  injury  to  the  brow  and  sub- 
sequent caries  of  the  margin  of  the  orbit 
(from  a  patient  in  the  Philadelphia  Gen- 
eral Hospital). 


Fig.  98. — Ectropion  of  the  lower 
lid,  the  result  of  a  wound  from  the  tine 
of  a  fork  (from  a  patient  in  the  Chil- 
dren's Hospital). 


Two  other  varieties  of  entropion  are  described — muscular  and 
bulbar.  The  former  is  sometimes  present  at  birth  from  undue  develop- 
ment of  the  orbicularis,  and  also  occurs  in  a  spasmodic  type,  under  the 
influence  of  conjunctivitis,  keratitis,  foreign  bodies  and  sometimes 
after  operations  and  bandaging  of  the  lids;  the  latter  is  a  falling-in 
of  the  lids  when  the  eyeball  is  shrunken  or  absent. 

Treatment. — The  spasmodic  varieties  will  usually  subside  if  the 
exciting  cause  can  be  removed.  In  temporary  entropion  the  lid  may 
be  painted  with  flexible  collodion,  which,  by  its  contraction,  draws  out 
the  inverted  border,  or,  having  everted  the  lid,  it  may  be  held  in  place 
with  a  longitudinal  strip  of  plaster  which  is  fastened  to  the  cheek.     The 

13 


194 


DISEASES    OF   THE    EYELIDS 


organic  varieties  of  the  disorder  require  one  or  other  of  the  operations 
described  on  page  608. 


Fio.  99. — -Ectropion  of  the  lower  lid, 
caused  by  caries  of  the  malar  Ijone  (from 
a  patient  in  the  Philadelphia  General 
Hospital). 


Fiu.  lUU. — Ectropion  of  the  upper  lid 
from  syphilitic  periostitis  of  the  orbit 
(from  a  patient  in  the  Philadelphia  Gen- 
eral Hospital). 


''/*}*■< 


-<&>..■■ 


Ectropion,  or  aversion  of  the  Hd  with  exposure  of  the  conjunctival 

surface,  is  either  partial  or  complete. 
The  disorder  is  divided  into  the  acute  or 
muscular  and  the  chronic  form,  or  that 
which  results  from  organic  changes. 

Acute  ectropion  usually  occurs  in 
children  with  conjunctivitis  and  in  dis- 
eases ofj.the  cornea  with  blepharospasm, 
when  the  lids,  during  examination, 
become  everted  and  remain  so  until  re- 
placed. One  form  of  partial  nuis- 
cular  ectropion  is  produced  by  facial 
|>alsy. 

The  common  causes  of  the  second, 
,  ^  or  chronic. form  of  ectiopion  are  woimds 

and  lesions,  for  example,  such   as  are 
jt  '      ,      caused   by  dog-bites,   by   laceration  of 

^^  ^,  the  lid  by  a  sharp  instrument,  by  burns 

i^B    ^^-  aiid^ subsequent  cicatricial  contraction. 

by  chronic  inflammatory  coiiditictns  of 
llie  ciliary  margin,  by  ulc(Mali»)M  of  the 
lids  as  in  lupus,  and  by  c;u"ies  of  the  or- 
bit;il  Ixuderand  ni;ilarbone.     'Ihe  lower 

lid  is  nioic  fi-('(|ii('nl  1\-  in  vol  veil  than  the  upper,  I  ml  ectidpion  is  .also  seen 

in  llie  l.aller  posilion. 


J'lti.  101.  liclropitin  iif  (111- lower 
lid  followiiiK  lupus.  Thesciir<ui  the 
cheek  is  faintly  si>en  (from  a  put  lent 
in  the  Ihiiveraily  Hospital). 


J 


MOLLUSCUM  CONTAGIOSUM  195 

Treatment. — This  varies  with  the  type  and  degree  of  the  ectropion. 
In  the  spasmodic  forms  simple  replacement  of  the  everted  lids  suffices ; 
in  slightly  marked  grades,  with  some  eversion  of  the  lacrimal  punctum, 
the  canaliculus  should  be  partly  slit,  and,  if  necessary,  the  nasal  duct 
should  be  probed;  sometimes  the  condition  is  favorably  influenced  by 
painting  the  everted  conjunctiva,  which  usually  is  thickened  and 
roughened,  with  an  astringent,  for  example,  tannin  and  glycerin  or 
boroglycerid.  The  organic  types  of  the  disorder  require  a  plastic 
operation  for  the  relief  of  the  deformity  (see  chapter  on  Operations). 

Certain  diseases  of  the  eyelids  depend  upon  disorders  of  the  seba- 
ceous and  sweat-glands. 


Fig.  102. — Dermoid  cyat  of  the  eyebrow. 

Seborrhea,  or  that  disorder  of  the  sebaceous  glands  during  which 
their  secretion  is  altered  and  forms  an  oily  coating  on  the  skin,  some- 
times coexisting  with  crusts  and  epithelial  scales,  is  also  seen  upon 
the  eyelids.  It  is  usually  associated  with  a  similar  process  in  the  scalp 
and  eyebrow,  and  when  specially  localized  upon  the  ciliary  margins 
creates  one  of  the  forms  of  blepharitis  already  described. 

Treatment. — Proper  hygiene,  cod-liver  oil,  iron  and  arsenic,  removal 
of  the  accumulated  sebum  by  frequent  washings,  and  the  application 
of  sulphur  and  mercurial  ointments  comprise  the  most  efficient  methods 
of  treatment. 

Milium. — ^Milia,  or  small  yellowish  elevations,  consisting  of  an 
accumulation  of  sebum  within  the  distended  but  closed  sebaceous 
glands,  are  common  upon  the  eyehds.  They  often  develop  about  the 
age  of  puberty. 

They  are  caused  by  improper  care  of  the  skin,  and  may  be  con- 
nected with  general  constitutional  disturbances,  dyspepsia,  and  consti- 
pation. They  should  be  opened  with  a  knife  or  needle  and  the  con- 
tents evacuated. 

Molluscum  contagiosum  (molluscum  sebaceum)  is  a  disease 
of  the  sebaceous  glands  (according  to  some  authors,  of  the  rete  muco- 


196  DISEASES    OF   THE    EYELIDS 

sum)  characterized  by  the  appearance  of  rounded  papules,  about  the 
size  of  a  pea.  and  of  a  waxy  color.     The  eyelids  are  a  favorite  situation. 

The  disorder  occurs  chiefly  among  ill-nourished  children,  is  believed 
by  many  to  be  contagious,  and  may  arise  as  an  epidemic  in  homes  and 
asylums.  According  to  some  ob.servers,  the  affection  is  caused  by  a 
parasite  belonging  to  the  class  coccidia.  and  really  is  a  form  of  contagi- 
ous epithelioma.  Muetze's  investigations  indicate  that  the  "mollus- 
cum  corpuscles"  are  the  result  of  a  degeneration  of  the  epithelial  cells 
caused  by  the  contagion,  the  nature  of  which  is  uncertain. 

Treatment. — Each  molluscum  should  be  incised  and  its  contents 
forced  out. 

Ephidrosis  {hyperidrosis),  or  an  increased  flow  of  sweat,  has  in 
rare  instances  been  observed  as  a  local  disorder  of  the  sweat-glands  of 
the  eyelids.  In  cases  of  unilateral  sweating  of  the  face  the  lids  neces- 
sarily participate.  Retention  cysts  of  the  sweat-glands,  in  the  form  of 
round,  sharph'  circumscribed  elevations,  have  been  observed  by  von 
Michel. 

Chromidrosis  (seborrJicea  7iigricans),  or  the  formation  of  a  variously 
colored  secretion  from  functionally  disordered  sweat-glands,  is  some- 
times located  upon  the  ej'elids.  It  then  receives  the  name  of  palpebral 
chromidrosis,  and  consists  of  a  bluish-black  discoloration,  usually  upon 
the  lower  lid,  which  is  somewhat  oleaginous  and  can  be  wiped  away. 

It  is  probably  genuine  in  rare  instances;  in  others  it  is  believed  to 
be  either  a  fraud  practised  by  hysteric  subjects  or  due  to  the  deposit 
of  dust  upon  the  surface  of  the  skin  affected  with  seborrhea.  Young 
women  are  usuallj^  those  affected. 

The  treatment  should  consist  in  general  invigorating  methods  cal- 
culated to  remove  anemia,  debilit}',  or  nervous  disturbances.  Locally, 
lead-water  and  glycerin  are  recommended. 

Sebaceous  cysts  occur  in  the  eyelids,  most  frequently  in  the  outer 
part,  and  also  in  the  eyebrow.  In  the  latter  situation  they  sometimes 
are  deeply  seated,  tightly  adherent  to  the  periosteum,  and  may  extend 
some  distance  into  the  orbit.  Dermoid  cysts  are  also  found  in  this 
region.  Th(Mr  r(>nu)val  by  an  ordinary  dis.section  is  usually  unatti'uded 
with  difficulty. 

Injuries  of  the  Eyelids. — Incised,  lacerated,  punctured,  and 
contused  wounds,  ed(Mna,  emphysema,  and  ecchymosis  of  the  lids  are 
the  ()r(liii;ir\-  i-esults  of  accidents  and  injuries. 

Wounds. — The  type  of  a  wound  depends  largely  up()n  the  char- 
acter of  the  implement  which  has  inflicted  it.  and  may  vary  from  a 
simple  and  superflcial  incision  to  a  deej)  cut  which  penetrat(>s  the  ti.ssues 
of  the  lid  and  injures  the  structuics  of  the  eyeliall.  In  like  manner  a 
laceration  may  be  small  and  unimportant,  or  may  be  .so  extensive  as 
to  tear  the  eyelid  fioni  its  attachments.  Incised  wounds  in  the  line 
of  the  direction  ot  the  fiheis  of  the  orliieularis  resuh  in  the  least  visible 
Kcar,  owing  to  the  absence  of  gaping.  Such  injuries  are  tifleii  inflicted 
by  broken  ghiss  (a  broken  spectacle  lens,  for  example)  or  china,  by  a 
knife  oi-  other  sharp  inst  rumen  t ,  and  l>y  a  thin  sliver  of  niet;d.      1  >uiiiig 


INJURIES    OF    THE    EYELIDS  197 

the  past  war  eyelid  wounds,  often  in  association  with  grave  facial 
wounds,  were  extremely  common. 

Treatment. — Approximation  of  the  edges  of  the  wound  should 
be  secured  with  catgut,  horse  hair  or  fine  silk  sutures.  Even  considera- 
ble laceration  may  heal  with  very  little  deformity  if  the  technic 
described  is  adopted.  The  important  points  are  that  the  sutures 
should  be  apphed  as  early  as  possible  after  the  injury,  that  if  the  wound 
is  a  penetrating  one  the  conjunctiva  should  be  carefully  sutured  and  the 
line  of  lashes  restored  before  the  skin  wound  is  approximated,  that, 
especially  necessar}^  in  the  case  of  multiple  wounds,  all  tissue 
should  be  retained  the  retention  of  which  is  feasible  and  that  the 
stitches  should  be  neatly  inserted  and  with  due  regard  to  a  coaptation 
of  the  lacerated  parts  in  their  proper  positions. 

Edema  usually  occurs  as  the  sequel  of  a  blow,  owing  to  the  loose 
connective  tissue  of  the  e3'elids,  which  is  readily  distended  (see  also 
page  169). 

Treatment. — The  application  of  evaporating  lotions,  for  example, 
dilute  lead-water  and  laudanum,  associated,  if  the  swelling  is  great, 
with  a  pressure  bandage,  is  a  measure  which  will  afford  relief. 

Emphysema  of  the  lids  is  observed  when  a  fracture  of  the  orbit 
permits  air  to  escape  into  the  cellular  tissue  through  a  communication 
thus  produced  with  the  ethmoidal  or  frontal  sinus.  A  soft  swelling, 
crackling  to  the  touch,  is  the  result,  which  increases  in  degree  when  the 
patient  blows  his  nose  and  forces  the  air  through  the  fissured  bone. 
The  eyelids  ma}-  participate  in  the  emph^'sema  of  the  neck  and  face 
sometimes  seen  after  tracheotomy  or  after  stab-wounds  of  the  chest. 

Ecchymosis  of  the  lids,  or  a  collection  of  blood  in  the  connective 
tissue,  in  its  simplest  variety  constitutes  the  familiar  "black  ej^e,"  the 
common  result  of  a  blow.  A  gradual  absorption  of  the  effused  blood 
takes  place,  requiring  a  week  or  longer  for  its  completion,  but  the  skin 
may  retain  its  black-and-blue  stain  for  a  greater  period  of  time. 

Ecchymosis  may  be  due  to  fracture  of  the  base  of  the  skull,  and 
may  be  associated  with  emphj'sema  if  a  fracture  has  involved  the 
frontal  or  ethmoidal  cells. 

Treatment. — Emphj'sema  will  gradually  subside  without  local 
treatment;  if  the  swelhng  is  severe,  it  has  been  recommended  to 
prick  the  tissues  and  allow  the  air  to  escape. 

Ecchymosis  should  be  treated  with  frequent  applications  of  cold 
water,  lead-water  and  laudanum,  or  diluted  white  extract  of  hama- 
melis.  If  discoloration  remains  for  a  long  time,  the  "eye  may  be 
painted."  The  practice  of  applying  leeches  or  incising  the  swollen 
lid  and  sucking  out  the  contained  blood  is  to  be  condemned. 

Foreign  Bodies  in  the  Eyelids. — Fragments  of  glass,  shot,  pieces 
of  iron  or  steel,  portions  of  wire,  particles  of  stone,  and  splinters  of 
wood  may  penetrate  the  tissue  of  the  eyelids  and  occasionalh^  remain 
undetected  for  long  periods  of  time.  They  may  become  encysted  or, 
as  the  result  of  infection,  give  rise  to  a  lid  abscess.  If  the  foreign  body 
is  composed  of  iron  or  steel  it  may  be  removed  by  means  of  a  magnet. 


198  DISEASES    OF   THE    EYELIDS 

Burns  of  the  eyelids  are  commonly  inflicted  with  hot  water,  caustics 
(lye  and  lime),  acids,  or  are  caused  by  the  explosion  of  powder. 

The  first  agent  produces  the  ordinary  vesication,  and  the  treatment 
should  consist  in  the  application  of  oil,  while  the  pain  maj*  be  materi- 
ally relieved  by  using  locally  a  lotion  of  carbonate  of  soda  or,  better, 
the  moistened  powder  itself. 

Burns  caused  by  the  other  materials  are  especially  dangerous  on 
account  of  the  almost  invariable  involvement  of  the  cornea  and 
conjunctiva  (see  page  257).  Immediately  after  a  powder  burn  all 
loose  powder  should  be  removed.  Deeply  embedded  grains  can  some- 
times be  picked  out  with  a  fine  needle;  usually  a  spot  of  discoloration 
remains.  E.  Jackson  has  suggested  that  large  powder  grains  may 
be  destroyed  by  touching  them  with  a  fine  electrocautery  needle,  to 
be  followed  by  the  ordinary  applications  suited  to  burns.  Peroxid  of 
hydrogen  is  a  most  efficient  remedy  for  powder  burns;  the  afifected 
skin  areas  should  be  vigorously'  rubbed  with  this  medicament  in  full 
strength  or  in  a  solution  of  3  parts  to  1  part  of  glycerin. 


CHAPTER  VI 
DISEASES  OF  THE  CONJUNCTIVA 

Congenital  Anomalies  of  the  Conjunctiva. — In  addition  to 
dermoid  tumors  (see  page  308)  certain  thickenings  of  the  conjunctive 
of  congenital  origin  have  been  reported.  The  latter  resemble  pterygia 
and  extend  between  the  fissures  of  the  lid  (Strawbridge) .  If  necessary, 
excision  could  be  performed  (see  also  Epitarsus,  page  168). 

Hyperemia  of  the  conjunctiva  {dry  catarrh;  hyperoemia  palpe- 
hraris)  is  characterized  by  an  injection  of  the  vessels,  chiefly  of  the 
palpebral  conjunctiva,  but  rarely  affecting  the  ocular  expansion  of 
the  membrane.  The  posterior  conjunctival  vessels  (System  I)  are 
involved,  but  not  to  the  same  extent  that  they  are  in  conjunctivitis. 
Both  an  acute  and  a  chronic  form  exist. 

Causes. — The  strain  of  ametropia  furnishes  a  large  contingent  of 
these  cases,  while  others  arise  when  the  refractive  error  is  insufficiently 
or  improperly  corrected.  Beginning  presbyopia,  especially  in  those 
persons  who  are  disinclined  to  use  glasses,  and  hyperemia  of  the 
conjunctiva  are  often  associated;  it  also  occurs  with  incipient  cataract 
and  slight  opacities  of  the  cornea,  as  the  result  of  the  effort  to  obtain 
clear  images. 

Local  irritants,  as  dust,  foreign  bodies,  misplaced  cilia,  calcareous 
concretions,  tobacco-smoke,  cold  winds,  etc.,  are  common  causes,  and 
the  abuse  of  alcohol  originates  many  cases.  The  condition  may  also 
arise  in  the  eyes  of  those  much  exposed  to  bright  light,  to  great  heat — 
for  example,  in  iron  foundries  and  among  workers  in  x-ray  rooms. 
Patients  with  prominent  eyeballs  are  more  liable  to  hyperemia  than 
those  whose  eyes  are  more  deeply  placed. 

Nasal  catarrh,  lacrimal  obstruction,  and  marginal  blepharitis  are 
frequently  accompanied  by  chronic  hyperemia  of  the  conjunctiva, 
which  is  much  aggravated  by  the  establishment  of  an  acute  coryza  or 
"hay-fever." 

Finally,  certain  acute  hyperemias,  which  may  be  recurrent,  appear 
in  the  form  of  vasomotor  disturbances,  and  arise  under  the  influence 
of  metabolic  disorders,  especially  gout.  Hyperemia  of  the  conjunctiva 
also  occasionally  occurs  in  anemia  and  chlorosis  in  place  of  a  pallid 
membrane,  and  may  be  associated  with  trigeminal  neuralgia  and 
migraine.  Chronic  conjunctival  congestion  has  been  attributed  to 
gastro-intestinal  auto-iritoxication  (J.  F.  Shoemaker). 

SjTnptoms. — Direct  inspection  reveals  the  congestion  of  the  vessels,, 
not  sufficient  to  produce  the  velvety  appearance  seen  in  conjunctivitis 
and  unaccompanied  by  any  discharge.  Swelling  of  the  conjunctival 
follicles  may  be  present,  especially  if  the  hyperemia  is  of  long  standing, 

199 


200  DISEASES    OF    THE    COX.IINCTIVA 

Thoro  arc  photophobia,  sonic  lacriination,  a  hot,  stinging  sensation 
aggravated  by  the  use  of  the  eyes,  which  reacUly  "water"  and  grow 
iinconifortablc,  especially  in  artificial  light. 

Treatment.— This  reciuircs  the  correction  of  refractive  error. 
Removal  of  exciting  local  causes  and  attention  to  the  anterior  and 
posterior  nares  are  necessary.  Patency  of  the  canaliculi  antl  of  the 
lacrimal  passages  should  be  secured. 

Locally,  boric  acid,  gr.  x  to  f5j  (0.65  gm.  to  30  c.c),  or  biborate  of 
soda,  gr.  v  (0.324  gm.),  camphor  water,  f5j  (30  c.c),  and  distilled 
water,  fgj  (30  c.c),  may  be  applied.  More  active  astringents,  as 
alum,  tannin,  and  zinc,  are  sometimes  emploj-ed,  and  stimulating 
drops,  for  instance  boric  acid  solution,  to  which  a  few  drops  of  alcohol 
have  been  added,  are  useful.  Nitrate  of  silver  is  not  advisable; 
argyrol  (10  per  cent.)  is  sometimes  useful.  Douching  the  eyes  with 
hot  or  cold  water  is  a  valuable  adjuvant.  Temporary  blanching  of 
the  conjunctiva  for  the  purpose  of  differentiating  deep  aiul  super- 
ficial injection  maybe  secured  with  adrenalin  (I  :  10,000)and  i)repa- 
rations  of  suprarenal  extract,  but  they  are  not  advisal)le  as  frequent 
or  constant  applications.  If  there  is  reason  to  suspect  any  general 
trouble — for  example,  gout — this  must  receive  attention. 

Conjunctivitis. — The  conjunctiva  is  liable  to  various  grades  and 
types  of  iitjlainiiKitioii  whicli  have  certain  symptoms  in  connnon:  (1) 
Photophobia,  not  constanth'  present  in  all  varieties,  but  conunonly 
seen  at  some  time  during  the  course  of  the  disease;  (2)  increased  and 
usually  altered  secretion;  (3)  a  changed  appearance  in  the  membrane, 
varying  from  a  general  injection  of  \\\v  blood-vessels  and  slight  velvety 
opacity  to  the  development  of  si)ecial  pathologic  jiioducts  or  the 
formation  of  false  membrane. 

The  generic  term  conjunctivitis  {ophthabnia  of  the  t)Uler  writers) 
is  applicable^  to  this  entire  group  of  diseases.  Although  bacteriologic 
examinations  have  given  rise  to  a  classification  of  conjunctivitis  which 
has  been  reconnnended  in  place  of  the  older  arrangement,  our  knowl- 
edge is  not  yet  sufficiently  exact  to  make  it  expedient  to  banish  entirely 
descriptions  based  upon  clinical  appearances.  It  should  be  remem 
Ix'red  that  the  noinial  conjunctiva  always  contains  bacteria,  a  number 
of  varieties  having  been  isolated.  Comparatively  few  of  tlu>m  should 
be  classified  as  at  all  pathogenic  (Weeks);  bill  non-pathogenic  bacteria 
may  become  harmful  if  the  tissues  in  whicli  tlu'\-  exist  are  bruiseil  or 
irritated.  Accoidinu;  to  Axenfeld,  (he  xerosis  hocillns  ami  non-viru- 
lent, or  only  slight  1\-  viiulent.  Staplii/lococcus  ulhns  are  practically 
always  present  in  the  normal  conjunertiva;  other  organisms  occasionally 
found  are  SUiphylococcus  pyoiicnvs  aimtis  and  dlbus.  pmiiniococcus. 
Strcptucoccus  pyoqeiwn  (rare),  iliplobacilhts  ;ind  injlucnza  bocHliis 
(iMicoiiiuion),  lidcilhis  suhlilis,  ;nid  .sf</T///<r. ' 

'  .\l!ic( '.ill.iii  lias  cliissilird  tlic  viirioiis  iDriiis  of  cuiijuiu'tnilis  <'iicoiiiit»'itHl  in 
EK.VJit  from  tli<'  huclcriolojric  stiiiulpoiiit  into  four  nroii|).s:  tin-  noiuu'oro;il  Kioiip, 
the  K(»cli-Wci'Us  uroiij),  llii?  .Moi;i\- AxiMifold  k'""!'-  •■""'  •'""  ,i;i'<»>i|»  tliu"  to  otIuT 
ornanisiii.s. 


il 


SIMPLE    CONJUNCTn'ITIS  201 

Simple  Conjunctivitis  {Catarrhal  Conjunctivitis  or  Ophthalmia). — 
This  is  an  inflammatory  disease  of  the  conjunctiva,  characterized  by 
congestion,  loss  in  the  transparency  of  the  palpebral  conjunctiva, 
some  dread  of  light  and  spasm  of  the  lids,  and  a  discharge  sufficient 
only    to  glue   the  lids  in  the  morning,   or  freer  and  mucopurulent. 

Causes. — The  etiology  is  made  evident  by  observing  certain 
varieties : 

Associated  conjunctivitis  is  seen  with  eczema,  facial  erysipelas,  im- 
petigo contagiosa,  nasal  catarrh,  bronchitis,  and  rheumatism  and 
typhoid  fever  (typhoid  bacilli  has  been  found  in  the  secretion  of  con- 
junctivitis in  this  disease).  In  acne  rosacea  conjunctivitis  minute  no- 
dules form  at  the  limbus;  moderate  irritation  supervenes;  subsidence 
takes  place,  but  recurrence  is  frequent.  The  condition  resembles 
somewhat  phlyctenular  conjunctivitis.  It  arises  in  adults  who  are  the 
subject  of  acne  rosacea.  Exanthematous  conjunctivitis,  which  accom- 
panies or  follows  measles,  scarlet  fever,  and  small-pox,  mscy  be  included 
in  this  list.  In  the  conjunctivitis  of  epidemic  meningitis  IMcKee  has 
found  the  meningococcus.  This  conjunctivitis  is  an  early  sj-mptom, 
and  ]\IcKee  thinks  the  bacteria  may  be  found  in  the  conjunctival 
secretion  before  they  can  be  recovered  from  the  cerebrospinal  fluid. 

Mechanical  conjunctivitis  results  from  exposure  to  wind,  dust,  and 
traumatism  {toxic  conjunctivitis,  see  page  244). 

Symptomatic  conjunctivitis  may  arise  from  the  strain  of  ametropia,, 
and  is  analogous  to  ordinary-  hyperemia. 

]Micro-organisms  (staphj-lococci,  streptococci,  pneumococci)  are 
present  in  severe  types  and  explain  the  contagion;  neglected  hypere- 
mias and  the  presence  of  follicular  granulations  increase  the  suscep- 
tibihty  to  infection,  and  scrofulous  subjects  are  peculiarly  liable  to  the 
disease.  Occasionalh'  a  stubborn  conjunctivitis  is  encountered  from 
the  secretion  of  which  pure  cultures  of  staphylococci  may  be  obtained, 
and  which  therefore,  has  been  called  Staphylococcus  conjunctivitis. 
]\IcKee  has  described  a  variety  of  mucopurulent  conjunctivitis  due  to 
a  new  pathogenic  organism  which  somewhat  resembles  the  influenza 
bacillus.  One  variety  of  conjunctivitis  is  due  to  the  Micrococcus 
catarrhalis,  and  is  often  accompanied  by  rhinopharj-ngitis.  It  may  be 
comparatively  mild  in  its  manifestations,  but  severe  and  decidedly 
mucopurulent  and  sometimes  epidemic  types  occur  .  In  this  connec- 
tion it  is  important  to  remember  that  the  micrococcus  catarrhahs  resem- 
bles the  gonococcus  in  morpholog}^  and  staining.  Conjunctivitis  may 
also  be  caused  by  the  presence  of  the  meningococcus,  Bacterium  coli 
(Axenfeld),  ozena  bacillus,  and  Bacillus  subtilis  (Gourfein). 

Symptoms. — The  secretion  is  at  first  watery,  and,  by  running  over 
the  edge  of  the  lids,  ma\'  excoriate  the  surrounding  skin,  which  shows 
injection  of  its  superficial  veins.  In  certain  individuals  the  lids,  espe- 
cially along  their  palpebral  margins,  are  slightly  edematous. 

The  secretion  soon  becomes  mucous  or  mucopurulent,  and,  accord- 
ing to  the  grade  of  the  inflammation,  gathers  in  a  slightl}-  froth}-  mate- 
rial only  at  the  commissural  angles,  or  is  more  freely  secreted. 


202  DISEASES    OF   THE    CONJUNCTIVA 

There  are  a  general  hyperemia  and  loss  in  the  transparency  of  the 
tarsal  conjunctiva,  in  which  the  posterior  conjunctival  vessels  (Sys- 
tem I)  are  concerned,  and  later  of  the  fornix,  caruncle,  and  semilunar 
folds. 

Although  vision  is  not  usually  affected,  some  secretion  may  be  ad- 
herent to  the  cornea  and  produce  the  same  haziness  in  sight  that  would 
be  present  on  looking  through  a  dirty  glass;  and  artificial  lights,  which 
are  most  uncomfortable  at  all  times,  appear  fringed  with  colored 
borders. 

Photophobia  may  be  entirely  absent,  or  exist  in  marked  degree  in 
those  varieties  which  complicate  measles,  or  which  are  associated  with 
the  development  of  superficial  ulcers  on  the  cornea.  All  ages  of  Ufe  are 
liable  to  catarrhal  conjunctivitis,  but  the  majority  of  the  cases'are 
seen  in  children  and  young  people. 

Prognosis  and  Duration. — The  prognosis  of  ordinary  catarrhal 
conjunctivitis  is  perfectly  good,  and  the  process  usually  subsides 
in  a  few  days.  One  or  both  eyes  may  be  affected.  In  other  types 
the  duration  may  be  prolonged  and  the  manifestations  severe,  sometimes 
because  of  neglect  and  improper  medication  (see  also  page  206). 

Acute  Contagious  (Communicable)  Conjunctivitis  (Acute 
Mucopurulent  Conjunctivitis;  Epidemic  Conjunctival  Catarrh;  "Pink 
Eye;"  Koch-Weeks'  Bacillus  Conjunctivitis). — This  form  of  conjunc- 
tivitis may  be  classified  as  the  severe  and  epidemic  type  of  the  variety 
of  conjunctival  affection  just  described.  By  some  writers  it  is  con- 
sidered as  a  distinct  disease. 

Etiology. —  The  majority  of  cases  are  caused  by  a  small  bacillus 
discovered  independently  by  Koch  in  the  acute  conjunctivitis  of 
Egypt,  and  by  Dr.  John  E.  Weeks  in  New  York,  and  studied  by  ^lorax 
and  others  in  Europe.  This  bacillus  resembles  that  of  mouse-septice- 
mia,  and  measures  1  to  2  /x  in  length  and  about  0.25  n  in  breadth.  It  is 
often  associated  with  a  clubbed  bacillus  (xerosis  bacillus).  It  stains 
readily  with  ordinar}'^  anilin  d^'es.  Some  observers  have  maintained, 
but  have  not  demonstrated,  that  the  Koch-Weeks'  bacillus  and  the 
influenza  bacillus  are  identical,  and  that  acute  contagious  conjunctivitis 
is  a  manifestation  of  influenza.  The  disease  may  occur  at  any  age,  ex- 
cept perhaps  during  the  first  few  days  of  life,  and  is  widi^sprc^ad  over 
the  world.  It  is  connuonest  in  warm  and  changeabli>  weather  (the  fall 
and  spring),  is  markedly  contagious,  and  will  pass  rapidly  from  one 
member  of  :i  household  to  another. 

Symptoms. — The  period  of  incubation  is  about  thirty-six  hours, 
and  the  disease  begins  with  the  symptoms  of  a  mild  catarrhal  con- 
junctivitis, but  usually  on  the  third  day  develops  into  a  severe  form  of 
conjunctivits,  in  which  the  entire  conjunctiva  is  deeply  injected  and 
small  hemorrhages  may  be  observed  (hemorrhagic  catarrhal  conjuTic- 
tivitis),  the  swelling  of  the  conjunctival  meinl)rane  being  noticeai)le  in 
opaque  velvety  layers,  especially  in  the  region  of  the  retrotiusal  fold. 
Sometimes  the  bulbar  conjunctiva  is  chemotic,  sometimes  brightly 
injected.     The  lids  are  glued  together  in  the  morning,  and  occasionally 


PNEUMOCOCCUS    CONJUNCTIVITIS  203 

they  are  decidedly  swollen  and  edematous;  the  eyes  are  hot  and  heavy, 
and  feel  as  though  they  contained  sand.  The  secretion  is  at  first  thick 
and  ropy,  and  may  be  gathered  into  long  strings  of  mucopus.  Later,  in 
some  cases,  the  discharge  becomes  distinctly  purulent.  The  acute 
stage  lasts  from  four  to  ten  days,  and  recovery  may  be  expected  in 
about  two  weeks.  Toward  the  end  of  the  disease,  or  in  what  may  be 
known  as  the  subacute  stage,  the  retrotarsal  folds  are  swollen  and  the 
papillary  body  is  enlarged.  Follicular  hypertrophy  is  at  times  also 
observed,  and  if  care  is  not  taken  the  affection  may  last  for  a  long  time. 
Both  eyes  are  almost  always  involved,  sometimes  simultaneouslj^  and 
sometimes  one  a  day  or  two  in  advance  of  its  fellow.  Corneal  com- 
plications, that  is,  ulcers  occasionally  occur  (Morax,  Shumway).  Hy- 
popyon has  been  observed  (Morax). 

Diagnosis  and  Prognosis. — The  actual  diagnosis  depends  upon 
microscopic  examination  and  the  finding  of  the  specific  micro-organism, 
but  the  clinical  signs  are  very  striking,  particularly  the  character  of  the 
secretion,  with  its  tendency  to  gather  in  yellowish  masses  toward  the 
inner  canthus.  If  the  disease  is  known  to  be  epidemic  at  the  time,  or  if 
it  is  shown  to  have  passed  from  one  member  of  the  family  to  another, 
the  diagnosis  becomes  still  more  certain. 

The  prognosis  is  good  in  the  majority  of  the  cases,  although  relapses 
and  recurrences  are  common,  and  one  attack  does  not  create  immunity. 
The  affection  through  neglect ,  however,  may  prove  exceedingly  trouble- 
some, and  tends  to  attack  all  members  of  a  household,  a  fact  which,  in 
asylums  and  similar  institutions,  may  prove  of  serious  import. 

Pneumococcus  Conjunctivitis. — This  form  of  conjunctivitis, 
due  to  the  Frankel-Weichselbaum  diplococcus  (pneumococcus),  was 
originally  described  by  Parinaud  and  Morax,  and  was  supposed  by 
them  to  be  an  affection  of  earlj^  childhood;  indeed,  it  is  more  common  in 
children  than  in  adults,  but  no  age  of  hfe  is  exempt.  While  it  is  not  as 
communicable  as  the  Koch- Weeks'  bacillus  conjunctivitis,  its  com- 
municable nature  is  well  established,  and  it  may  be  transferred  from 
one  eye  to  another,  from  one  person  to  a  second,  and  as  Gasparrini, 
Harold  Gifford,  Veasey,  the  author  and  a  number  of  other  observers 
have  noted,  may  appear  in  epidemic  form,  although  usually  not  so 
extensively  or  frequently  as  the  Koch- Weeks'  conjunctivitis.  How- 
ever, very  marked  epidemics  of  this  type  of  conjunctivitis  have  been 
observed,  some  for  example  in  camps  and  cantonments  during  the  late 
war.  Bacterial  findings  vary  according  to  time  and  place.  Thus 
in  Philadelphia  during  the  prevalence  of  acute  conjunctivitis  the  pneu- 
mococcus usually  is  more  in  evidence  than  the  Koch- Weeks'  bacillus, 
while  the  latter  micro-organism  is  common  in  New  York.  According  to 
Axenfeld,  pneumococcus  conjunctivitis  is  more  prevalent  in  northern 
countries  and  in  cold  months  of  the  year  than  other  forms  of  mucopurulent 
conjunctivitis.  Very  rarely  it  is  associated  with  pneumonia;  a  coryza 
may  accompany  or  precede  it. 

Symptoms. — Usually  it  begins  as  an  ordinary  conjunctivitis,  the 
conjunctiva  being  reddened  and  secreting  a  rather  thin  mucopurulent 


204  DISEASES    OF   THE    COXJUNCTrV'A 

discharge,  in  whicli  small  floc-culcnt  masses  float.  The  upper  lid  is 
edematous  and  pinkish  in  color,  the  lashes  lip,htly  matted,  and  lat^r  the 
discharaje  becomes  thicker  and  more  j:)urulent,  and  sometimes  resembles, 
in  severe  cases,  that  found  in  purulent  conjunctivitis.  Small  subcon 
junctival  hemorrhages  may  appear.  The  clinical  manifestations  of 
this  form  of  conjunctivitis  are  often  difficult  to  distinguish  from  Koch- 
Weeks'  bacillus  conjunctivitis.  According  to  Gasparrini.  in  pneumo- 
coccus  conjunctivitis  a  fine  pellicle  of  fibrin  can  be  wiped  from  the 
everted  upper  tarsus,  which  is  not  met  with  in  Weeks'  bacillus  con- 
junctivitis. Generally  the  disease  lasts  from  six  to  ten  daj's,  and  the 
prognosis  is  favorable;  rarely  corneal  complications  have  been  noted; 
occasionally  iritis  develops,  due  to  absorption  of  the  toxin,  without 
implication  of  the  cornea  (Axenfeld). 

Influenza^bacillus  Conjunctivitis. — This  form  of  conjunctivitis, 
due  to  the  influenza  bacillus  (Pfeiffer's  bacillus),  has  been  especially 
studied  by  Zur  Nedden,  Morax,  Jundell,  and,  in  this  country,  by  Arnold 
Knapp.  Clinically,  the  manifestations  of  the  disease  are  not  severe:  it 
is  characterized  by  a  copious,  thin  discharge,  and  affects  chiefly  the  con- 
junctiva of  the  lids  and  retrotarsal  folds.  The  majority  of  cases  have 
occurred  in  \^oung  children  and  infants,  in  whom  it  is  more  severe  than 
in  adults,  who  are  rarely  attacked.  Although  the  local  disease  presents 
a  favorable  prognosis,  and  usually  disappears  in  from  ten  to  fourteen 
days,  it  may  be  associated  with  rhinotracheitis,  dacryocystitis,  and 
inflammation  of  the  middle  ear.  Arnold  Knapp  has  described  a 
pseudomembranous  form  of  influenza  bacillus  conjunctivitis  of  great 
severity,  wliich  may  caus(>  perforation  of  the  cornea. 

Swimming=bath  Conjunctivitis. — This  form  of  conjunctivitis  is 
encountered  among  those  who  frequent  public  baths.  In  many  in- 
stances the  symptoms  are  analogous  to  those  wliieh  occur  in  catarrhal 
conjunctivitis,  although  the  discharge  is  less  abundant.  Often  the 
bulbar  conjunctiva  is  coarselj'  injected.  In  two  local  epidemics  of  this 
disease  in  two  large  schools  equipped  with  swinnning-pools  investigated 
by  the  author  the  micro-organism  found  was  in  one  instance  the  pneu- 
mococcus,  and  in  another  an  uniilentified  bacillus.  Sometimes  the 
afTection  resembles  acute  trachoma,  and  l^aderstein  has  been  abU'  to 
demons' r;it  (■  "inclusion  Ixxlies." 

Diplobacillus  Conjunctivitis  {Mordx-Axvnfckl  Bacillus  Con- 
junctivitis, Atigular  Conjunctivitis,  Subacute  Conjunctivitis). — This 
foiin  of  conjunctivitis,  due  to  a  diplobacillus  2  to  3  /x  in  breadth,  often 
occunitig  in  cliains,  was  originally  described  by  Mo'ax  and  l)v  Axen- 
feld aliroad,  and  laid'  was  stutlied  by  Ilaiold  GilTord  in  this  country. 

Symptoms.— One  variety  of  the  dis(\ise  is  insidious  in  character, 
and  runs  a  rather  tedious  course,  dining  which  the  main  .symptoms  are 
redness  and  slight  induialion  of  the  edges  of  the  lids,  particularly  «»f 
the  conunissural  angles,  and  congestion  of  the  neigliboring  conjuni'tiva. 
In  other  worils,  the  signs  are  those  of  a  bk'phar(H'onjunctiritis  or  uiKjular 
coujunclivitis.  The  abnormal  secretion  is  gr.-iyish  white  :ind  not 
abundant,  and  has  a  tendency  tn  adhcic  to  the  icddened  lid  ni.-irgins 


DIPLOBACILLUS    CONJUNCTIVITIS 


205 


and  to  gather  in  small  masses  at  the  angles,  especially  the  inner  one. 
This  clinical  manifestation  is  so  constant  that  it  is  well-nigh  charac- 
teristic, and  if  there  is  any  doubt,  the  diagnosis  is  readily  established 
by  finding  the  bacilhis  in  the  secretion. 

On  the  other  hand  the  reaction  of  the  conjunctiva  to  the  Morax 
bacillus  is  often  acute,  or  the  inflammation  may  be  confined  to  the 
conjunctiva  without  special  participation  of  the  lid  angle,  or  the  disease 
may  resemble  an  acute  conjunctival  catarrh  with  swelling.  In  other 
words,  it  may  vary  from  a  mild 
hyperemia  of  the  conjunctiva 
to  a  severe  mucopurulent  con- 
junctivitis (McKee).  Morax- 
Axenfeld  conjunctivitis  may 
attack  persons  of  all  ages,  but 
is  more  common  in  adults  than 
in  young  persons.  It  is  widely 
distributed  over  the  world.  It 
may  arise  at  any  season,  but 
is  said  to  be  more  frequent  in 
summer  than  during  cold 
weather.  McKee,  however, 
found  the  greatest  number  of 
cases  in  January.  Diplobac- 
illary  conjunctivitis  may  be  ac- 
companied by  a  nasal  catarrh, 
and  the  diplobacilli  are  found 
in  the  nasal  secretion. 

The  disease  may  last  from  six  weeks  to  six  months,  but  if  improperly 
treated  may  remain  for  much  longer  periods  of  time.  Its  duration  is 
readily  shortened  by  proper  treatment.  It  may  be  associated  with 
follicular  and  phlyctenular  conjunctivitis,  and  corneal  complications 
may  arise,  either  in  the  form  of  superficial  infiltrations  or  deep  ulcers, 
from  which  the  bacillus  may  be  cultivated  {diplobacillary  keratitis). 
Iritis  without  corneal  implication  has  been  observed  (Ernest  Thom- 
son). Occasionally  these  ulcers  are  complicated  with  hypopyon  and 
iritis  (L.  Paul). 

Petit  has  isolated  a  bacillus  resembling  the  Morax-Axenfeld  or- 
ganism which  can  produce  a  conjunctivitis  like  the  one  just  described. 
It  may  also  attack  the  cornea  primarily  and  is  capable  of  originating 
hypopyon-keratitis.  The  Bacillus  pyocyaneus  sometimes  causes  a 
conjunctivitis  which  yields  to  zinc  sulphate  (Brown  Pusey). 

Treatment  of  Conjunctivitis. — (a)  Siynple  Conjunctivitis. — This 
consists,  first,  in  search  for  the  cause  and  the  alleviation  of  as.sociated 
conditions.  The  patient  must  be  removed  from  the  influence  of  dust, 
cold  winds,  tobacco-smoke,  and  the  like;  the  under  surfaces  of  the  lids 
should  be  examined  for  foreign  bodies,  and  their  borders  for  misplaced 
cilia.  In  the  earlier  stages  cold  compresses  are  agreeable  and  suitable; 
sometimes  frequent  bathings  with  hot  water  are  more  acceptable.^    At 


Fig.  103. — The  diplobacillus  of  Morax  and 
Axcnfeld  (from  a  preparation  by  Dr.  Harold 
GifTord). 


206  DISEASES    OF   THE    CONJUNCTIVA 

first  a  solution  of  boric  acid,  as  collyriuin  or  spray — gr.  x  to  f5j  (.0.65 
gm.  to  30  c.c.)  is  useful.  The  eyelids  and  ciliary  margins  should  be 
frequently  washed  with  water  and  Castile  soap. 

As  soon  as  the  discharge  becomes  mucous  or  mucopurulent  and  the 
velvety  opacity  of  the  conjunctiva  forms,  a  stronger  solution  of  boric 
acid,  to  which  a  few  grains  of  common  salt  may  be  added,  is  advisable; 
and  the  everted  hds  may  be  painted  with  a  solution  of  nitrate  of  silver, 
gr.  v-x  to  f5j  (0.324-0.65  gm.  to  30  c.c),  and  suitably  neutrahzed. 
In  place  of  nitrate  of  silver,  protargol  (5-20  per  cent.)  and  argyrol 
(10-25  per  cent.)  are  frequently  emplo3-ed.  In  mild  cases  one  or  two 
applications  a  day  are  sufficient,  the  drug  being  dropped  into  the  con- 
junctival sac  and  allowed  to  spread  freely  over  the  inflamed  membrane. 
Argentamin  (2-5  per  cent.)  and  largin  (10  per  cent.)  are  also  recom- 
mended. In  severe  types,  with  a  considerable  discharge,  bichlorid  of 
mercury  (1:8000-10,000)  and  cyanid  of  mercury  (1:2000)  are  valuable 
collyria. 

Other  preparations  which  have  found  favor  are  alum,  gr.  iv-viii 
to  f5j  (0.26-0.52  gm.  to  30  c.c),  sulphate  of  zinc,  gr  ij'to  f5j  (0.13 
gm.  to  30  c.c),  which  may  be  suitablj^  combined  with  boric  acid, 
biborate  of  sodium,  gr.  iv-viij  to  f^j  (0.26-0.52  gm.  to  30  c.c),  per- 
oxid  of  hydrogen,  Panas'  fluid,  creohn  (1  per  cent.),  and  other  anti- 
septic collyria.  Should  the  thickening  of  the  retrotarsal  folds  prove 
stubborn,  after  the  acute  symptoms  have  subsided,  these  may  be 
touched  with  an  alum  crystal  or  a  solution  of  tannin  and  gycerin. 
Atropin  is  not  usually  necessary  unless  a  corneal  ulcer  comphcates 
the  affection. 

The  eyes  may  be  protected  with  smoked  glasses,  but  in  no  circum- 
stances should  they  be  bandaged  or  be  covered  with  poultices  of  tea- 
leaves  (which  of  themselves  may  produce  conjunctivitis — ''tea-leaf 
conjunctivitis"),  bread  and  milk,  scraped  potatoes,  and  the  like.  It 
should  be  remembered  that  meddlesome  domestic  medication  of  this 
sort  may  change  a  simple  conjunctivitis  into  a  serious  and  purulent 
inflammation. 

At  the  outset  a  laxative,  followed  by  full  doses  of  (luinin,  is  indi- 
cated; any  associated  disease  of  which  the  conjunctivitis  may  be  a 
symptom — e.y.,  rhinitis — requires  the  usual  treatment.  Proper  hy- 
giene, fresh  air,  strict  cleanliness,  and  protection  from  contaminated 
towels,  etc..  are  evident  indications. 

(6)  Acute  Contagious  Conjunctivitis. — The  trcatnu>nt  does  not 
differ  from  that  which  has  already  been  described  in  connection  with 
simple  conjunctivitis.  Weeks  recommends  biehlorid  of  mercury  (1; 
10,000)  as  a  collyriuin.  Usually  art-iyroi  and  jjrotargol  are  prescribed, 
and  they  may  act  elTciently,  but  it  is  a  mistake  to  permit  patients 
themselves  to  use  these  preparations  for  long  perioils  of  time.  As 
Risley  has  aptly  said,  they  may  originate  a  new  set  of  conjunctival 
catarrhs,  and  give  rise  to  a  troublesome,  tumid,  hypereinic  condition  of 
the  conjwncitiva;  also  Uuy  may  stain  the  nienil)r;ine.  Applications  of 
nitrate  of  silver,  in  llir  usual   ni.iniicr.  to  the  everted  lids  are  useful. 


EXANTHEMATOUS    CONJUNCTIVITIS  207 

Iced  compresses  afford  relief  during  the  height  of  the  affection.  In 
place  of  the  ordinary  collyria,  chlorid  of  zinc,  1  grain  (0.065  gm.)  to 
the  ounce  (30  c.c),  is  highly  recommended;  sulphate  of  zinc,  gr.  ij  to 
f5j  (0.13  gm.  to  30  c.c),  is  also  valuable. 

(c)  Pneumococcus  Conjunctivitis. — In  this  affection  the  treatment 
already  described  in  the  preceding  paragraphs  is  efficient.  Sulphate  of 
zinc  drops  are  useful;  ethylhydrocuprein  may  be  applied  in  the  usual 
manner  to  the  everted  lids  in  a  2  per  cent,  solution  or  be  used  as  a 
collyrium  (3^^-!  per  cent.).  Mercurophen  (1-8000)  achieves  excellent 
results. 

(d)  Influenza-bacillus  Conjunctivitis. — The  usual  collyria  and  anti- 
septics are  advisable.  Zur  Nedden  recommends  nitrate  of  silver  (1.5- 
2  per  cent.),  oxycyanid  of  mercury  (1:1500),  and  iced  compresses. 

(e)  Diplohacillus  Conjunctivitis. — In  this  disease  the  preparations  of 
zinc  are  practically  specifics.  They  may  be  employed  in  the  form  of 
the  sulphate  (0.5-1.5  per  cent.)  or  the  chlorid  (0.2  per  cent.).  A 
useful  method  is  to  paint  the  everted  lids  with  2-3  per  cent,  solution 
of  sulphate  of  zinc  once  a  day  and  provide  the  patient  with  0.5  per 
cent,  solution  to  be  used  freely  and  frequently.  Nitrate  of  silver, 
argyrol  and  protargol,  in  contradistinction  to  their  valuable  action 
in  other  varieties  of  conjunctivitis,  are  of  no  use.  Todd  recommended 
sozoiodolate  of  zinc  (1-2  per  cent.)  and  ichthyol  ointment  (10  per  cent.). 

Catarrhal  Epidemic  Conjunctivitis  {Catarrh  with  Swelling;  Epi- 
demic Catarrh). — Certain  systematic  writers,  notably  Saeiiiisch  and 
Schmidt-Rimpler,  although  the}''  consider  this  disease  to  be  a  form  of 
acute  conjunctiv^al  catarrh,  give  it  a  separate  description  on  account  of 
certain  distinguishing  features,  namel}^,  swelling  not  only  of  the  lid 
margin,  but  of  the  entire  lid  itself,  which  seems  to  be  increased  in 
volume  and  is  reddened,  together  with  tumefaction,  infiltration,  and 
marked  hyperemia  of  the  retrotarsal  folds.  The  secretion  is  consider- 
able in  quantity,  mucopurulent  in  character,  and  often  mixed  with 
small  fibrinous  masses.  Both  eyes  are  usually  affected,  and  persons 
of  any  age  may  be  attacked.  It  has  appeared  with  notable  frequency 
among  scrofulous  children,  especially  if  they  are  also  the  subjects  of 
exanthematous  disease  of  the  face.  The  secretion  should  be  consid- 
ered as  distinctly  contagious,  and  the  disease  has  appeared  in  the  form 
of  small  epidemics.  Sometimes  it  is  a  sequel  of  influenza.  In  the 
secretion,  pneumococci,  staphylococci  and  streptococci  have  been 
found.  The  treatment  should  include  thorough  irrigation  of  the 
conjunctival  sac  with  bichlorid  of  mercury  (1  :8000),  cyanid  of  mercury 
(1 :5000),  mercurophen  (1:8000)  or  a  saturated  solution  of  boric  acid. 
The  swollen  and  inflamed  retrotarsal  folds  may  be  treated  with 
applications  of  1  to  2  per  cent,  solutions  of  nitrate  of  silver  in  the  usual 
manner,  or  in  their  place  protargol  and  argyrol  may  be  employed. 

Exanthematous  Conjunctivitis. — This  form  of  conjunctivitis 
has  been  briefly  referred  to  in  connection  with  catarrhs  of  the  conjunc- 
tiva, and  is  particularly  noteworthy  as  part  of  the  manifestations  of 
measles,  scarlet  fever,  and  small-pox.     The  disease  may  not  only  ac- 


208  DISEASES    OF   THE    CONJUNCTR'A 

company  these  exanthems,  but  often  arises  prior  to  their  eruption. 
Sniall-i)ox  pustules  sometimes  develop  on  the  conjunctiva.  Occasion- 
ally the  conjunctivitis  of  measles  assumes  a  very  severe  type,  so  severe 
that  it  may  resemble  a  blennorrhea,  and  Fuchs  has  noted  under  these 
conditions  a  suppurative  inflammation  of  the  Meibomian  glands.  The 
investigations  of  Schottelius  indicated  that  staphylococci  and  strepto- 
cocci are  active  in  the  conjunctivitis  of  measles,  streptococci  being 
especially  conmion  in  fatal  cases. 

Among  the  chronic  exanthemata  of  the  conjunctiva,  acne  rosacea 
is  important  (see  also  page  201),  and  in  this  disease  minute  nodules 
may  form  with  marked  irritation  near  the  liml)us.  The  conjunctiva 
may  also  be  implicated  in  i)ityriasis.'  psoriasis,  and  herjies  iris.  Its 
involvement  in  s^-philis,  pemphigus,  lupus,  and  lepra  is  elsewhere  de- 
scri])ed. 

Treatment. — The  treatment  of  exanthematous  conjunctivitis  does 
not  diffci-  from  that  of  the  catarrhal  form  of  the  a^^ection  and  its  varie- 
ties. Fuchs  recommends  the  local  application  of  calomel  as  especially 
valuable  in  acne  rosacea  of  the  conjunctiva. 

Unusual  Forms  of  Conjunctivitis. — A  very  rare  form  of  con- 
junctivitis or  conjunctival  disease  is  ''squirrel  plague  conjunctivitis,"' 
described  by  Derrick  Vail  and  Robert  Sattler,  due  to  an  infection  with 
the  Bacillus  iularense,  identified  by  McCoy  and  Chapin  as  the  germ 
of  squirrel  plague.  In  Vail's  patient  the  symptoms  were:  intense 
chemosis,  mucoid  secretion,  enlarged  preauricular  glands,  and  deep 
yellow  necrotic  ulcers  in  the  palpebral  conjunctiva.  Sanioan  Conjunc- 
tivitis, according  to  Eby  is  acutely  infectious  and  is  characterized  by 
its  rapid  onset,  the  intensity  of  the  conjunctival  inflanunation,  pain 
and  dread  of  light.  The  discharge  quickly  becomes  purulent  and  de- 
structive corneal  involvement  may  be  a  comjilication.  Infectious 
necrotic  conjunctivitis  according  to  Pascheff,  ])egins  with  constitution- 
al sj-mptoms.  There  are  enlargement  of  the  preauricular  and  submax- 
illary glands,  reddening  of  the  tarsal  conjunctiva  and  infiltration  of  the 
retrotarsal  folds,  with  formation  of  white  spots  which  break  down 
into  ulcers.  The  disease  is  said  by  Pascheff  to  last  from  one  to  three 
weeks.  He  failed  to  identify  the  bacteria  which  were  found.  The 
similarity  of  the  manifestations  of  this  disease  and  those  of  squirrel 
plague  conjunctivitis  is  suggestive. 

Purulent  conjunctivitis  (acute  blennin-rhea  of  the  conjunctiva) 
occurs  in  three  spccidc  loiiiis:  in  the  newboi'ii  (ophthalniia  neonatorum), 
in  young  girls  (occasioii.-dix'  boys),  and  in  atlults  {(jonm-rheal  conjunc- 
tivitis ()!•  ophthalmia) . 

Conjunctivitis  Neonatorum  (Ophthahniti  Xeonalorum).-  This  is 
an  infi.'uniMatiori  of  the  conjunctiva,  charMclerized.  in  its  usual  form,  by 
great  swelling  of  the  lids,  serous  inliltralion  of  the  Itulbar  conjunctiva, 
and  the  free  secretion  of  contagious  pus. 

Causes.  The  ;i(Tection  is  most  fre(|uently  eaused  liy  the  introdiic- 
tioii  into  the  eye  of  llie  infecting  ni.'ilerial  from  some  poition  of  the 
genito-urin;iiy    tniel    (»f    tlie    niotlier   ;il    the    time   of   or   sliorlK'    :ifter 


CONJUNCTR'ITIS   NEONATORUM  209 

birth.  The  majority  of  cases  (60-70  per  cent.)  are  associated  with  a 
special  micro-organism — the  gojiococcus  of  Neisser.  Exceptionally, 
inoculation  occurs  in  utero,  owing  to  the  penetrating  power  of  the 
gonococcus  or  to  infection  after  rupture  of  the  membranes  {antepartum 
conjunctivitis) . 

]\Iany  observers  have  demonstrated  that  ophthalmia  neonatorum 
is  not  alwaj'S  gonorrheal  in  origin,  but  may  be  produced  by  various 
kinds  of  micro-organisms — pneumococcus,  streptococcus,  diplobacillus. 
Bacterium  coli,  and  Staphj^lococcus  albus,  aureus,  and  citreus.  It  is 
possible  that  some  forms  of  conjunctivitis  neonatorum  are  reallj^  types 
of  influenza-bacillus  conjunctivitis;  the  acute  purulent  conjunctivitis 
due  to  the  micrococcus  catarrhalis  has  been  referred  to.  According 
to  Stephenson,  next  to  the  gonococcus  the  pneumococcus  is  the  common- 
est organism  found  with  ophthalmia  neonatorum.  Inclusion-hlennor- 
rhea  of  the  newborn  is  referred  to  elsewhere  (see  page  216). 

Inasmuch  as  the  gonococcus  is  not  invariably  present,  two  forms  of 
the  disease  have  been  distinguished — a  severe  type,  caused  bj^  the 
gonococcus,  with  a  tendency  to  increase  in  severity  and  invade  the 
cornea;  and  a  milder  type,  non-specific,  with  a  tendency  to  recover. 
Hence,  a  virulent  vaginal  discharge  is  not  necessary  to  produce  this 
condition,  except  in  intense  degree,  and  it  probably  may  arise  from  the 
contamination  of  aavy  mucopurluent  discharge  during  birth,  and  from 
injudicious  intravaginal  antisepsis  with  strong  solutions  of  mercuric 
chlorid.  Careless  bathing  of  the  child  after  birth  and  the  use  of  soiled 
towels  and  sponges  are  fruitful  sources  of  infection.  Contact  with  the 
lochial  discharge  may  originate  the  disorder,  although  inoculation  with 
healthy  lochia  has  failed  to  produce  the  disease. 

The  exact  time  of  inoculation  has  not  been  determined.  Infection 
is  more  likely  to  occur  in  face  presentations  and  during  retarded  labors. 
Boys  are  attacked  more  frequenth'  than  girls.  The  disease  is  said  to 
be  more  common  during  summer  months  in  cold  climates;  in  hot  coun- 
tries, during  the  spring  and  autumn. 

S5rmptoms. — Conjunctivitis  neonatorum  usualh'  begins  on  the 
third  daj'  after  birth,  but  may  set  in  as  early  as  from  twelve  to  forty- 
eight  hours  after  inoculation,  or,  where  it  is  the  result  of  a  secondary 
infection  from  soiled  fingers,  sponges,  or  cloths,  be  delayed  to  a  much 
later  date.  Late  gonococcic  infections  have  been  explained  b}-  Crede- 
Horder  on  the  assumption  that  the  Xeisser  organisms  do  not  find  their 
way  directly  into  the  conjunctival  sac  during  birth,  but  may 
be  hidden,  for  example,  in  Meibomian  glands.  Non-gonorrheal  cases 
do  not  usually  arise  until  after  the  fifth  to  the  seventh  day.  In  con- 
junctivitis neonatorum  almost  always  both  eyes  are  attacked,  the  one 
being  earlier  and  frequently  more  decidedh'  affected  than  its  fellow. 

Four  stages  of  the  disease  are  common,  but  as  these  vary  in  different 
cases,  and  more  or  less  rapidly  shade  one  into  the  other,  no  very  sharp 
lines  need  be  drawn. 

A  slight  redness  of  the  conjunctiva,  with  a  trifling  discharge  in  the 
corner  of  the  eye,  is  rapidh'  succeeded  by  great,  cushion-Hke  swelling 

14 


210  DISEASES    OF   THE    CONJUNCTIVA 

of  the  lids,  with  intense  chemosis  and  congestion  of  the  conjunctiva, 
accompanied  by  severe  pain  and  discharge.  The  surface  of  the  swollen 
lid  is  hot,  dusky  red,  and  tense;  the  upper  lid  overhangs  the  lower,  and 
at  first  can  be  everted  only  with  difficulty.  The  discharge,  which  in 
the  beginning  is  sightly  turbid,  soon  changes  to  a  yellow  or  greenish- 
yellow  pus,  and  is  secreted  in  great  quantities. 

If  the  lids  are  everted  during  the  first  day  or  two  of  the  disease,  the 
conjunctiva  will  be  found  to  be  swollen,  red,  and  velvety,  and  that 
upon  the  eyeball  intensely  injected;  upon  the  surface  easily  detached 
flakes  of  lymph  are  found;  later,  the  conjunctiva  becomes  rough  and  of 
a  dark-red  color,  spots  of  ecchj-'mosis  appear,  or  it  is  succulent  and 
bleeds  easily.     Marked  chemosis  and  infiltration  of  the  ocular  conjunc- 


»sft*? 


«?**-■ 


Fig.   104. — Conjunctivitis  neonatorum    (from  a  patient  in  the  Philadelphia  General 

Hospital) . 

tiva  succeed,  forming  a  hard  rim;  at  the  bottom  of  the  crater-like  pit 
thus  produced  the  cornea  may  be  seen.  The  thick,  cream-like  dis- 
charge increases,  and  cither  flows  out  from  beneath  the  overhanging 
upper  lid  on  to  the  cheek  or  is  packed  up  in  the  conjunctival  culdesac 
(Fig.  104).  Hometimes  false  membrane  forms  and  covers  the  tarsal 
conjunctiva;  indeed,  the  appearances  may  be  exactly  like  thosi^  of  a 
membranous  conjunctivitis. 

The  lids  now  may  lose  much  of  their  tense  character,  ;uul  can  l)e 
more  easily  everted;  the  conjunctiva  is  puckered  into  folds  and  papilla- 
like elevations,  and  the  discharge  contains  an  admixture  of  l^lood  and 
serum.  Gradually  the  disease  declines,  and  in  from  six  to  eight  weeks 
the  discharge  ceases.  The  relaxed  palpebral  conjunctiva  is  thick  and 
granular,  looking  like  the  granulation  tissue  which  surrounds  wounds. 
The  ocular  conjunctiva  is  also  thickened,  and  positive  cicatricial 
changes  may  remain. 

Th(»  chi(^f  risk  is  deslruclion  of  tlie  vil;ility  of  the  cornea,  the  danger 


CONJUNCTIVITIS    NEONATORUM  211 

of  which  is  materially  increased  if  this  membrane  becomes  lusterless, 
dull,  and  hazy  within  the  first  day  or  two  of  the  disease,  and  the  gono- 
coccus  is  freely  present  in  the  discharge.  Frequently  small  oval  ulcers 
form  near  the  limbus,  either  transparent  or  surrounded  by  an  area  of 
cloudy  infiltration,  which  rapidly  increase  in  size;  or  larger  areas  of 
ulceration  develop  in  a  more  central  situation.  In  many  mild  cases 
the  cornea  escapes  without  harm.  The  changes  which  take  place  in 
the  cornea  are  due  in  part  to  strangulation  of  its  nutrient  vessels  by  the 
swollen  tissue,  but  largely  to  direct  infection  by  the  discharge.  Cor- 
neal lesions  do  not  usually  occur  in  eyes  if  the  discharge  is  free  from 
gonococci. 

After  the  formation  of  a  corneal  ulcer,  either  its  healing  and  regen- 
eration of  the  corneal  tissue  takes  place  or  else  perforation  occurs. 

The  result  of  perforation  will  depend  upon  the  amount  and  charac- 
ter of  the  destruction  of  the  corneal  tissue.  If  the  ulcer  is  central  and 
perforates,  the  aqueous  humor  escapes,  the  lens  is  pressed  forward 
against  the  posterior  surface  of  the  cornea,  and  the  opening  becomes 
closed  with  lymph.  Restoration  of  the  anterior  chamber  follows,  and 
the  lens  returns  to  its  proper  position,  carrying  with  it  upon  the  ante- 
rior capsule  a  little  mass  of  lymph.  Thus  the  formation  of  a  pyr- 
amidal cataract  results  (see  page  438).  Fuchs  maintains  that  in  the 
formation  of  opacities  following  corneal  suppuration  the  lens  epi- 
thelium is  rarefied  by  destruction  of  the  cells;  later  there  is  prolifera- 
tion of  the  remaining  cells  and  capsular  cataract  results. 

Perforation  of  an  ulcer  peripherally  situated,  especially  below,  is 
followed  by  adhesion  of  the  iris  to  the  opening.  The  aqueous  escapes, 
and,  as  the  iris  and  the  lens  fall  forward,  the  former  becomes  entangled 
in  the  perforation  and  is  fixed  by  inflammatory  exudation.  The  adhe- 
sion is  either  on  the  posterior  surface  or  in  the  cicatrix,  and  the  resulting 
dense  white  scar  receives  the  name  adherent  leukoma. 

If  the  region  of  the  scar  is  bulged  forward  because  it  is  unable  to 
resist  the  intra-ocular  tension,  anterior  staphyloma  results.  Extensive 
sloughing  of  the  corneal  tissue,  with  total  prolapse  of  the  iris,  matting 
together  of  the  parts  by  exudation,  and  protrusion  of  the  cicatrix  con- 
stitute a  total  anterior  staphyloma. 

Finally,  perforation  may  be  followed  by  inflammatory  involve- 
ment of  the  ciliary  body  and  choroid,  and  the  rapid  destruction  of  the 
eye  through  panophthalmitis,  or  a  slower  shrinking  of  the  tissues,  with 
atrophy  of  the  hulh.  Dense  opacity  occasionally  appears  in  the  cornea 
during  convalescence,  and  may  go  on  to  ulceration  or  clear  up  perfectly. 
It  may  arise  with  great  suddenness,  and,  should  it  occur  in  the  lower 
half  of  the  cornea,  a  deep  indentation,  owing  to  the  pressure  of  the 
margin  of  the  lid,  is  likely  to  occur. 

The  appearance  of  the  conjunctiva  differs  materially  in  different 
cases.  Its  surface  may  be  covered  over  not  merely  with  easily  de- 
tached flakes  of  lymph,  but  with  a  gray,  false  membrane.  More  rarely  a 
deep  infiltration  develops,  like  that  seen  in  diphtheritic  conjunctivitis. 

Restlessness,  fever,  and  other  constitutional  disturbances  are  some- 


212  DISEASES    OF   THE    CONJUNCTIVA 

times  present,  and  synovitis  of  the  knee  and  wrists  may  arise,  of 
the  same  character  as  arthritis  occurring  in  adults  during  gonorrhea. 
Rhinitis,  infection  of  the  lacrimal  gland,  meningitis,  endocarditis,  and 
general  septicemia  have  been  reported  as  complications  of  ophthalmia 
neonatorum.  In  rare  instances  pneumococcus  conjunctivitis  neona- 
torum may  be  associated  in  the  second  week  with  inflammation  of  the 
knee-joint  (Stephenson). 

Conjunctivitis  neonatorum  does  not  always  follow  this  course,  be- 
cause the  term  is  made  to  include  affections  of  the  conjunctiva  in  the 
newborn  other  than  the  types  just  described — mild  catarrhal  con- 
junctivitis, hyperemias,  and  that  variety  which,  according  to  Noyes, 
presents  the  character  of  a  granular,  rather  than  of  a  purulent,  con- 
junctivitis, and  which  may  continue  for  weeks  without  danger  of  cor- 
neal complication.  Occasionally  a  gonococcal  conjunctivitis  pursues 
the  course  of  a  simple  conjunctival  catarrh  (Groenouw).  Further- 
more, as  Saemisch  has  said,  purulent  conjunctivitis  may  develop  in 
newborn  children  not  due  to  the  gonococcus  (see  also  page.  209),  but 
caused  either  by  other  virulent  bacteria  or  by  non-bacterial  agents. 
Necessarih'  the  manifestations  are  less  violent  than  those  of  gonococ- 
cal origin,  and  for  these  varieties  the  name  acute  blejinorrhagic  con- 
junctivitis neonatorum  has  been  suggested. 

Some  hyperemia  of  the  conjunctiva,  with  a  little  yellowish  dis- 
charge in  the  corners  of  the  eye  and  slight  swelling  of  the  lower  lid.  is 
common  in  babies  for  a  few  days  after  birth. 

Diagnosis. — The  onset  and  character  of  the  typical  disease,  its 
symptoms  and  course,  render  a  mistake  in  regard  to  its  nature  prac- 
tically impossible.  Close  attention  should  be  given  to  what  at  first 
appears  to  be  a  trivial  inflammation  in  the  eyes  of  a  newborn  clnid. 
because  a  virulent  and  destructive  inflammation  may  follow  with  great 
rapidity.  Bacteriologic  examination  of  the  secretion  is  essential,  which 
should  include  not  only  smears  but  also  cultures  and  the  findings  will 
determine  the  true  character  of  the  disease. 

Prognosis. — ^This  is  always  grave  in  gonorrheal  cases,  but  with 
compet(;nt  medical  attendance,  if  the  eye  is  seen  while  the  cornea  is  still 
clear,  except  in  diphtheritic  types,  in  those  with  inherent  malignancy 
(Randall),  or  where  depreciation  of  nutrition  or  intercurrent  illness 
diminish  the  resisting  power  of  the  child,  the  majority  of  cases  should 
be  brought  to  a  succ(>ssful  termination.  Hence  the  attentlants  of  new- 
born children  should  be  compelleil  to  seek  medical  advice  jus  soon  as 
conjunctival  trouble  appears,  for  delayed  or  improper  treatment  means 
sloughing  of  the  cornea,  when  no  form  of  medication  can  do  more  than 
relieve  the  violence  of  the  inllaMuiial ion,  which,  after  it  subsides,  leaves 
the  child  with  sight  hopelessly  marred,  peili.ips  destroyeil.  The  prog- 
nosis of  the  niild  types  is  favoiiible. 

Prophylaxis. — The  present  higli  standrird  of  scienlilic  niiilwifeiy 
includes  sucli  cautious  antisepsis  prior  to.  and  during  labor  that  the  risk 
of  contamination  is  distinctly  less  than  in  former  times,  but  still  .some 
pre\'eiit  i\c  method  should  be  employed. 


CONJUNCTIVITIS    NEONATORUM  213 

The  eyes  of  those  children  who  have  passed  through  a  birth-canal 
known  to  be  infected,  or  from  which  the  suspicion  of  infection  cannot 
positively  be  eliminated  prior  to  birth,  may  be  treated  according  to 
the  method  of  Crede,  which  is  as  follows :  As  soon  as  the  head  is  born 
the  lids  are  carefully  cleansed,  parted,  and  two  drops  of  a  2  per  cent, 
solution  of  nitrate  of  silver  are  instilled  into  each  conjunctival  sac. 
Small  cold  compresses  are  then  laid  upon  the  lids  and  renewed  at  suit- 
able intervals.  Occasionally  severe  reaction  follows — conjunctival 
hyperemia  or  catarrh  (the  so-called  "  silver  catarrh"),  and  even  hemor- 
rhage from  the  conjunctiva  and  corneal  haze.  Hence  it  is  not  always 
necessary  to  employ  a  2  per  cent,  solution  of  nitrate  of  silver,  inasmuch 
as  a  1  per  cent,  solution  will  be  of  sufficient  strength.  Wherever 
infection,  or  the  suspicion  of  infection,  can  be  positively  excluded, 
milder  measures — for  example,  washing  the  eyes  and  flushing  them 
with  a  saturated  boric  acid  solution — are  sufficient.  Other  materials 
recommended  are  aqua  chlorini  (Schmidt-Rimpler),  sophol  (5  per 
cent.)  (von  Herff,  R.  M.  Wilhams),  bichlorid  of  mercury  (1  :  5000), 
carbolic  acid  (1  per  cent.),  and  the  newer  silver  salts,  especially  argyrol 
(25  per  cent.)  and  protargol  (10  per  cent.).  The  last-named  remedies 
are  not  to  be  trusted  in  the  management  of  eyes  which  have  been  ex- 
posed to  gonorrheal  infection.  The  value  of  Crede's  method  is  so 
firmly  estabUshed  that  it  should  not  be  neglected  if  the  birth-canal  is 
known  to  be  infected  with  gonorrhea,  or  if  the  suspicion  of  infection 
cannot  be  excluded.  In  its  place  a  5  per  cent,  solution  of  sophol  has 
been  highly  recommended.  Axenfeld  advises  its  use  "instead  of  the 
formerly  employed  Crede's  silver  drops."  With  this  drug  the  author 
has  had  no  experience.  The  hands  of  the  mother,  nurse,  and  child 
should  be  searched  for  sources  of  infection,  and,  if  gonorrhea  is  known 
to  exist  in  the  mother,  the  child  should  be  isolated.  Conjunctivitis 
neonatorum  should  be  listed  as  a  reportable  disease,  and  laws  should  be 
enacted  to  this  effect,  and  these  laws  should  be  rigidly  enforced,  and  it 
should  be  possible  to  provide  the  affected  children  with  expert  atten- 
tion at  their  homes  or,  even  better,  with  hospital  accommodations. 
The  distribution  by  health  boards  of  circulars  of  advice  to  midwives 
and  mothers  and  of  tubes  containing  the  chosen  prophylactic  to  those 
who  are  qualified  to  use  it  (preferably  a  1  per  cent,  solution  of  nitrate 
of  silver),  should  be  required.  Happily,  there  has  been  a  real  advance 
in  the  methods,  legal  and  otherwise,  for  preventing  ophthalmia 
neonatorum,  but  much  work  remains  to  be  done.  As  ophthalmia 
neonatorum  is  the  cause  of  fully  8  per  cent,  of  blindness  in  this  coun- 
try, all  efforts  to  check  the  ravages  of  this  disease  cannot  too  strongly 
be  emphasized. 

Treatment. — If  the  type  is  mild,  the  applications  described  under 
simple  conjunctivitis  are  indicated;  if  severe,  three  conditions  demand 
attention:  the  inflammatory  swelling  of  the  lids,  the  state  of  the  con- 
junctiva, and  the  corneal  complications. 

1.  During  the  earlier  states,  when  the  lids  are  tense  and  the  secre- 
tion lacking  in  its  later  creamy  character,  in  addition  to  absolute 


214  DISEASES    OF   THE    CONJUNCTIVA 

cleanliness,  local  application  of  cold  is  a  useful  agent  in  a  certain  number 

of  cases. 

This  should  be  applied  in  the  following  manner:  Upon  a  block  of  ice 
square  compresses  of  gauze  are  laid,  which,  in  turn,  are  placed  upon  the 
swollen  lids,  and  as  frequently  changed  as  may  be  needful  to  keep  up  a 
uniform  cold  impression.  This  is  far  preferable  to  the  use  of  small 
bladders  containing  crushed  ice;  indeed,  the  use  of  ice  is  not  advisable. 
The  length  of  time  occupied  with  these  cold  applications  must  vary 
according  to  the  severity  of  the  case.  Sometimes  they  may  be  used 
almost  continuously,  and  sometimes  every  three  or  four  hours  for 
twenty  minutes  at  a  time.  Standish  and  other  surgeons  deny  the 
value  of  [the  use  of  cold  in  this  manner,  believing  that  it  adds  to 
the  danger  of  corneal  complications.  This  is  entirely  contrary  to 
the  author's  experience. 

It  must  be  emphasized,  however,  that  it  requires  a  good  deal  of 
experience  to  know  when  to  use  and  when  not  to  use  cold,  and  not  all 
cases  are  suited  to  its  application.  Hot  fomentations  have,  been  ad- 
vised, especially  where  corneal  compHcations  exist,  or  the  surface  of 
the  conjunctiva  is  covered  with  a  gray  film.  These  are  applied  with 
squares  of  antiseptic  gauze  wrung  out  in  carbolized  water  of  a  tempera- 
ture of  120°  F.,  and  frequently  changed.  The  author,  basing  his 
opinion  on  a  large  experience  in  the  Philadelphia  General  Hospital, 
doubts  their  efficiency. 

2.  Constant  removal  of  the  discharge  must  be  practised. 

The  lids  are  to  be  gently  separated,  the  tenacious  secretion  wiped 
away  with  bits  of  moistened  lint  or  absorbent  cotton,  and  the  con- 
junctival sac  gently  but  freely  irrigated  with  an  antiseptic  fluid.  For 
this  purpose  a  saturated  solution  of  boric  acid  (which  is  feebly  anti- 
septic, but  very  cleansing  and  slightl}'  astringent)  or  one  of  corrosive 
sublimate,  1  grain  to  1  pint — 0.065  gm.  to  480  c.c.  (strong  solutions 
should  not  be  used  because  they  may  injure  the  corneal  epithelium 
and  cause  ulceration),  may  be  employed.  Special  and  ingenious  forms 
of  lid  irrigators  have  been  devised,  but  are  unneces^sary  and  often 
harmful.  The  cleansing  process  nmst  be  repeated  at  least  every  hour, 
day  and  night,  and,  if  necessary,  much  more  frequently;  but  all  manipu- 
lations must  be  most  gentle  and  all  caution  not  to  injure  the  delicate 
structures  of  the  eye  must  be  maintained. 

3.  The  application  of  one  of  the  salts  of  silver. 

Until  comparatively  recent  times  nitrate  of  silver  was  almost  uni- 
versally employed,  a  drug  combining  the  properties  of  an  astringent  and 
a  superficial  caustic.  Its  germicidal  power,  however,  is  not  of  much 
avail,  as  this  is  fpiickly  impaired  l)y  contact  with  the  ti.»<sue  proteins. 
Once  a  day  the  palpebral  conjunctiva  and  retrotarsal  folds  should  be 
brushed  over  with  a  solution,  10  grains  (O.li')  gin.)  to  the  ounce  (30 
CO.)  their  surfaces  first  having  been  carefully  freed  from  any  adherent 
discharge,  and  afterward  all  excess  of  the  drug  washed  uway  witii  a 
solution  of  common  salt,  and  this  washing  continued  until  a  clean  red 
surfacf!  is  secured,  when  I  lie  lids  may  be  returned  to  tlieir  proper  posi- 


CONJUNCTIVITIS   NEONATORUM  215 

tion,  their  margins  greased  with  vaselin,  and  some  of  the  lubricant 
introduced  within  the  conjunctival  culdesac.  Great  care  must  be 
exercised  that  the  corneal  epithelium  shall  not  be  injured.  Ulceration 
of  the  cornea  does  not  alter  the  treatment  described.  A.s  long  as  the 
discharge  is  abundant  the  use  of  the  caustic  is  indicated,  and  it  may- 
be employed  from  the  very  beginning  of  the  disease  unless  the  con- 
junctiva is  covered  with  a  false  membrane,  which  would  prevent  its 
access  to  the  conjunctival  folds. 

Within  the  last  few  years  protargol  and  argyrol  have  largely  replaced 
nitrate  of  silver  in  the  treatment  of  ophthalmia  neonatorum  in  the  prac- 
tice of  many  surgeons.  Standish  recommends  the  following  routine 
treatment  or  "immersion  method."  The  edges  of  the  lids  are  washed 
with  a  solution  of  boric  acid  Once  in  half  an  hour,  and  they  are  anointed 
with  vaselin  to  prevent  them  from  sticking  together.  A  solution  of  pro- 
targol or  argyrol  is  instilled  freely  between  the  lids  at  intervals  of  from 
every  hour  to  once  in  four  hours.  This  fluid  sinks  to  the  bottom  of  the 
culdesac  and  floats  to  the  surface  the  pus  and  mucus,  which  can  readily 
be  removed  with  a  very  slight  amount  of  manipulation.  Protargol 
is  used  in  strengths  varying  from  10  to  40  per  cent.,  the  10  per  cent, 
solution  yielding  the  best  results.  Of  argyrol,  a  25  per  cent  solution 
is  satisfactory.  Henry  D.  Bruns  prefers  a  10  per  cent,  solu- 
tion of  argyrol  to  be  used  freely  every  half-hour  until  pus  secretion 
is  checked.  Then  he  apphes  in  the  usual  manner  nitrate  of  silver 
(0.2-1.0  per  cent.)  once  a  day.  Many  other  surgeons,  both  here  and 
abroad,  employ  these  drugs  in  a  similar  manner.  According  to  Stephen- 
son, in  gonorrheal  ophthalmia  neonatorum  a  25  per  cent,  solution  of 
argyrol  painted  once  or  twice  a  day  over  the  conjunctiva,  exposed  for 
that  purpose  by  eversion  of  the  lids  and  carefully  dried  from  adherent 
discharge,  with  the  frequent  use  by  instillation  of  the  25  per  cent. 
or  of  a  weaker  solution,  represents  a  method  of  treatment  more  promptly 
efficacious  than  any  other  with  which  he  is  acquainted. 

The  author's  experience  is  in  accord  with  the  good  results  ascribed 
to  the  methods  of  using  argyrol  just  described,  except  that  in  a  certain 
number  of  cases  the  argyrol  treatment  alone  is  not  sufficient,  and 
nitrate  of  silver  must  be  used,  especially,  as  Bruns  recommends,  in  addi- 
ition  to  or  after  the  use  of  argyrol.  In  other  words,  the  author  because 
of  a  large  experience  in  the  ophthalmic  wards  of  the  Philadelphia  Gen- 
eral Hospital,  is  unconvinced  that  nitrate  of  silver,  properly  applied  (p. 
214)  has  ceased  to  be  a  valuable  remedy  in  ophthalmia  neonatorum.^ 
Protargol  as  compared  with  argyrol  is  more  irritating  (although  not 
markedly  so)  and  does  appear  to  possess  special  advantages.  It  is 
usually  stated  that  argyrol  is  without  germicidal  properties,  but   a 

1  The  author  is  well  aware  that  many  surgeons  deprecate  the  use  of  nitrate  of 
silver  in  these  circumstances.  George  Derby,  for 'example,  thinks  the  reaction  in 
gonorrheal  conjunctivitis  is  too  great  to  permit  its  use  and  that  its  bactericidal 
power  cannot  assail  the  deep-seated  gonococci.  He  prefers  mild  remedies,  e.  g., 
argyrol.  E.  B.  Heckel  reports  excellent  results  from  constant  irrigation  alone 
with  iced  physiologic  salt  solution. 


216  DISEASES    OF   THE    CONJUNCTIVA 

recent  research  by  Lancaster  indicates  that  it  is  not  without  potency 
in  this  regard.  Its  chief  virtues,  however,  are  its  freedom  from  irri- 
tating quahties,  its  marked  detergent  effects  and  its  aljihty  to  penetrate 
between  the  folds  of  swollen  conjunctiva  and  liberate  the  secretion. 

At  the  first  appearance  of  corneal  haze  one  drop  of  a  0.5  per  cent, 
solution  of  atropin  is  to  be  dropped  into  the  eye  two  or  three  times  daily. 
During  corneal  complications  Darier  recommends  a  coiiyiium  contain- 
ing dionin,  pilocarpin,  and  cyanid  of  mercury. 

Persistent  swelling  of  the  conjunctiva  is  sometimes  treated  by  scari- 
fication. Division  of  the  outer  commissure  to  relieve  pressure  is  not 
suited   to  young  infants,   although   it  may   be   indicated   in   adults. 

If  one  eye  alone  is  affected,  suitable  protection  for  the  sound  eye 
should  be  provided.  This  may  be  accomplished  by  antiseptic  bandag- 
ing of  the  uninflamed  organ  (Buller's  shield  is  difficult  of  application  in 
infants). 

The  attendants  must  be  impressed  with  the  fact  that  upon  their 
faithful  carrying  out  of  directions,  and  upon  their  unremitting  care, 
much,  if  not  all,  of  the  hope  of  bringing  the  case  to  a  successful  termina- 
tion depends.  The  attendants  must  further  be  impressed  with  the  con- 
tagious nature  of  the  pus;  all  bits  of  rag  and  pledgets  of  lint  used  in  the 
treatment  must  be  destroyed,  and  after  each  treatment  the  hands  of 
those  engaged  must  be  thoroughly  washed  and  disinfected  with  a 
solution  of  bichlorid  of  mercury. 

Many  other  remedies  have  been  used  in  the  treatment  of  conjuncti- 
vitis neonatorum;  for  example,  those  mentioned  on  page  206  and  carbolic 
acid  (0.5  to  1  per  cent.),  iodoform  and  iodoform  ointment  (,4  per  cent.), 
aqua  chlorini,  cyanid  of  mercury  (1  :  1500),  permanganate  of  potassium 
(1:5000),  used  in  copious  irrigations,  formaldehyd  (1:5000),  and 
argentamin  (2  per  cent.).  Darier  suggests  a  3  per  cent,  solution  of  ich- 
thargan  if  protargol  loses  its  effect.  Blenolenicet  salve  has  been 
recommended  (Adams,  Scheuermann),  and  sophol  in  5  per  cent,  solution 
(von  Herff).  Antigonococcus  serum  has  been  trie'd  and  good  results 
have  been  reported.  These  remedies  do  not  seem  to  possess  virtues 
which  should  make  them  replace  those  which  iiave  been  more  fully 
described. 

Inclusion-blennorrhea  of  the  Newborn.  -In  certain  varieties  of 
conjunctivitis  neonatorum,  usually  non-gonorrheal  and  for  the  most 
pait  benign  in  nature,  the  (.lieinsa  stain  will  reveal  in  the  secretion  "epi- 
thelial inclusions,"  that  is,  clusters  of  sinail  giaiudes,  colored  violet  or 
dark  blue,  which  cap  the  nucleus  like  a  cowl.  According  to  Axenfeld, 
this  "inclusion-blennorrhea"  is  frequently'  unilateral,  the  retrotarsal 
fold  is  tumid,  and  if  the  disease  lingers  long  a  granular  condition  of 
the  conjunctiva  supervenes.  After  its  sul)sidence  sometimes  ilelicatt' 
cicatricial  tissue  remains.  Corneal  complications  are  not  in  evidtMice. 
Wheth(?r  these  "inclusions"  aic  llie  cause  of  this  disease  is  not  known 
(see  also  page  2'.V2). 

Purulent  Conjinictivitis  in  \ Oiin^  (iirls. — Occasionally  > oung 
girls  aic  the  subjects  of  vaginitis,  whicii  in  severe  forms  is  associated 


GONORKHEAL   CONJUNCTIVITIS  217 

with  a  purulent  discharge,  and  in  hospitals  and  asylums  has  occasion- 
ally assumed  the  form  of  an  epidemic  among  the  inmates.  In  a  certain 
percentage  of  these  cases  gonococci  are  present  in  the  discharge,  and  the 
disease  may  be  convej'ed  to  the  eye  by  the  fingers,  or  gain  entrance  into 
the  conjunctival  sac  from  discharge  adherent  to  bed-linen,  sponges,  etc. 
There  results  a  purulent  conjunctivitis,  with  symptoms  closely  re- 
sembhng  those  of  ophthalmia  neonatorum,  although  usually  the  mani- 
festations are  less  violent,  and  the  corneal  complications  less  likely  to 
occur  than  in  the  gonorrheal  conjunctivitis  of  adults.  To  this  disease 
the  name  ophthahyiohlennorrhea,  or  gonohlennorrhea,  of  young  girls  has 
been  given.  The  treatment  should  in  all  respects  conform  to  that 
which  has  been  described  in  connection  with  ophthalmia  neonatorum. 
If  properl}^  treated,  the  prognosis  is  good. 

Gonorrheal  conjunctivitis  {'purulent  ophthalmia;  acute  blennor- 
rhea in  adults)  usually  can  be  traced  to  the  source  of  infection  which 
arises  from  an  acute  gonorrhea  or  a  gleet,  by  contact  with  soiled  fingers 
or  Hnen,  or  from  an  eye  affected  with  this  form  of  conjunctivitis. 
Considering  the  frequency  of  gonorrhea  this  ocular  complication  is  not 
a  very  common  affection,  occurring  according  to  Wfiite,  quoted  by 
Duane,  about  once  in  eight  hundred  cases  of  gonorrhea.  If  all  sources 
of  infection  are  considered,  however,  it  is  probable  that  its  incidence 
is  greater  than  these  figures  indicate. 

The  same  micro-organism  described  in  connection  with  gonorrheal 
ophthalmia  neonatorum  is  active  in  gonorrheal  conjunctivitis,  the 
diplococci  being  found  within  the  cells;  later  they  penetrate  the  epi- 
thelium and  enter  the  lymph-spaces  in  the  subconjunctival  tissue. 

Symptoms. — The  first  sj^mptoms  appear  from  twelve  to  forty- 
eight  hours  after  inoculation,  and  resemble  those  already  recited 
in  connection  with  the  same  disease  occurring  in  the  newborn  (see 
page  209). 

The  vitality  of  the  cornea  is  in  constant  danger,  and  involvement 
of  this  membrane  may  arise  during  the  height  of  the  attack  or  later, 
and  when  convalescence  apparently  is  established.  This  consists  in 
ulcers,  small  and  large,  either  central  or  peripheral;  in  the  latter 
position  they  often  exist  as  grooved  rings  or  small  clean-cut  lesions 
without  infiltration,  hidden  by  the  swelling  of  the  surrounding  con- 
junctiva, and  very  prone  to  perforate;  or  they  may  coalesce  and 
form  a  ring  abscess.  A  more  or  less  dense  opacity  may  follow  ulcera- 
tion or  arise  independent!}'  of  this  condition. 

If  perforation  occurs,  all  the  phenomena  described  on  page  211  will 
ensue,  and  even  without  perforation,  iritis,  cyclitis,  and  disease  of  the 
deeper  structures  of  the  eye  may  develop  and  defeat  the  possibility  of 
obtaining  good  vision. 

Gonorrheal  conjunctivitis  reaches  its  climax  in  about  ten  days  and 
then  gradualh'  subsides  in  from  one  to  two  months;  or  it  may  pass  into 
a  chronic  type  and  be  one  of  the  forms  of  chronic  blennorrhea,  in  which 
there  is  general  redness  of  the  palpebral  conjunctiva,  with  hypertrophy 
of  its  superficial  layers  and  some  thickening  of  the  papillae. 


218  DISEASES    OF    THE    CONJUNCTWA 

Diagnosis. — This  is  readily  made  from  the  history  of  the  case,  and, 
above  all,  by  an  examination  of  the  secretion  for  tlic  nonococci  in 
stained  smears  and  by  cultures. 

Prognosis. — -The  prognosis  is  always  grave,  even  more  so  than  in 
conjunctivitis  neonatorum.  The  subject  of  fully  developed  gonorrheal 
conjunctivitis  comparatively  rarely  recovers  without  some  corneal  in- 
volvement, and  only  too  often  the  eye  is  hopelessly  marred.  It 
may  be  stated,  however,  that  the  prognosis  is  better  now  as  the  result 
of  improved  methods  of  treatment  than  in  former  times.  It  is  prob- 
able that  certain  cases  diagnosticated  as  true  gonorrheal  conjuncti- 
vitis which  have  yielded  with  astonishing  rapidity  to  therapeutic 
measure  have  not  been  due  to  a  Neisserian  infection.  The  difficulty 
of  distinguishing  between  the  gonococcus  and  the  micrococcus  catar- 
rhalis  has  been  discussed  (page  201).  Arthritis,  endocarditi.^,  and 
septicemia  may  arise  as  complications  (see  also  page  212). 

Treatment. — This  includes  the  same  principles  and  practice 
described  in  connection  with  ophthalmia  neonatorum  (see  page  213), 
but  requires  certain  modifications  suggested  by  the  adult  age  of  the 
majority  of  the  patients. 

If  the  swelling  of  the  lids  is  so  great  that  their  pressure  threatens 
to  destroy  the  cornea,  the  outer  canthus  may  be  divided  (canthot- 
omy).  This  acts  in  a  twofold  manner,  by  relieving  pressure  and  by 
depleting  the  engorgement  through  the  loss  of  blood  occasioned  by  the 
incision,  which  should  be  made  with  a  scalpel,  cutting  the  tissues  from 
without  down  to  the  bone  as  far  as  the  margin  of  the  orbit,  but  leaving 
the  conjunctiva  uninjured.  Repeated  incisions  of  the  hard  rim  of 
chemotic  conjunctiva  which  surrounds  the  cornea  will  also  relieve 
pressure,  and  in  some  circumstances  is  a  most  useful  procedure.  In 
desperate  cases  some  operators  (Critchett,  Fuchs)  have  not  hesitated 
to  split  the  lid  verticallj''  and  stitch  the  divided  portions  to  the  brow, 
restoring  them  by  a  plastic  operation  after  the  disease  has  subsided. 
Cold  may  be  applied  with  compresses  in  the  manner  already  described, 
or  continuously  with  Leiter's  tubes.  Certain  experienced  surgeons,  as 
has  already  been  mentioned  in  connection  with  ophthalmia  neona- 
torum, doubt  the  value  of  cold  applications.  The  author  believes  that 
in  gonorrheal  conjunctivitis  in  adults,  during  the  early  stage,  cold  is  not 
only  most  agreeable  to  the  patient,  relieving  pain  and  irritation,  but  of 
distinct  value  in  cliecking  the  inflammatory  process  and  \\\v  niovi^ment 
of  the  bacteria.  Not  all  cases  are  suited  to  cold,  and  it  is  not  always 
right  to  use  the  cold  continuously;  but,  as  is  well  maintained  by  Weeks, 
it  may  be  used  for  periods  of  twenty  minutes  to  half  an  hour  every 
tlir(!e  or  four  hours,  thus  ol)taining  the  therapcnitic  valu(^  of  the  cold 
and  avoiding  the  dangei-  of  depressing  tiie  nutrition  of  the  cornea. 

Local  api)lications  include  the  antiseptic  lotions  previously  recom- 
mended (see  page  215),  in  addition  to  which  may  be  mentioned  a  drug 
which  the  author  has  often  employed  in  the  wards  of  the  Philadelphia 
General  Hospital  with  suce(>ss,  namely,  peinianganate  of  potassium, 
1  :  2000-5000,  used  copiously,  a  |)iiit  :it  a  lime,  in  cont  inumis  inigat  ion 


Plate  II. 


Fi&J 


FisJI 


'^     - 


•  •As 


Fla.W 


Fia.m 


Fig.  I. — Discharge  from  right  eye  in  a  case  of  purulent  conjunc- 
tivitis ;  gonococci  numerous  in  cells  (Stephenson). 

Fig.  II. — Bacillus  of  Weeks  in  pure  culture  (from  a  photograph) 
(Weeks). 

Fig.  III. — Conjunctival  secretion  from  acute  contagious  conjunc- 
tivitis ;  polynuclear  leukocytes  v^^ith  the  bacillus  of  Weeks  ;  F,  Pha- 
gocyte containing  bacillus  of  Weeks;  immers.  Jj,  oc.  iii  (Morax). 

Fig.  IV. — Secretion  from  a  case  of  conjunctivitis,  showing  pneu- 
mococci ;   immers.  y'^?  oc.  iii  (Morax). 


GONOERHEAL    CONJUNCTIVITIS  219 

after  the  manner  of  Kalt,  These  irrigations  should  be  performed  three 
or  four  times  a  day,  according  to  the  severity  of  the  case  and  the  quan- 
tity of  the  discharge.  Nitrate  of  silver  should  be  used  in  the 
manner  described  on  page  214.  In  place  of  this  drug  argyrol  and 
protargol  have  been  much  employed.  According  to  Standish,  pro- 
targol  seems  to  act  somewhat  better  in  the  gonorrheal  conjunctivitis 
of  adults  than  argyrol.  These  drugs  should  be  applied  in  the  npanner 
already  described,  that  is,  by  the  immersion  method  (see  page  215). 
In  the  opinion  of  the  author,  argyrol  should  be  employed  in 
the  treatment  of  gonorrheal  conjunctivitis,  but  not  to  the  exclusion  of 
nitrate  of  silver,  which,  he  is  satisfied,  will  always  hold  a  high  position 
in  the  therapy  of  this  disease  in  adults.  With  subconjunctival  injec- 
tions in  the  treatment  of  serious  cases  of  gonorrheal  ophthalmia,  as, 
for  example,  they  have  been  recommended  by  Hirsch,  who  uses  a 
solution  of  oxycyanid  of  mercury,  1  :  5000,  to  which  acoin  is  added,  the 
author  has  had  no  experience.  Neither  has  he  faith  in  the  value  of 
peroxid  of  hydrogen  diluted  to  3  per  cent.,  which  has  been  recommended 
in  the  treatment  of  this  disease,  nor  has  he  had  an  opportunity  of 
testing  the  value  of  blenolenicet  ointment.  The  treatment  of  this 
disease  with  antigonococcus  serum  does  not  appear  to  have  been 
satisfactory. 

On  the  appearance  of  any  of  the  types  of  corneal  ulceration  atropin 
drops  should  be  instilled  with  sufficient  frequency  to  maintain  mydria- 
sis and  subdue  ciliary  hyperemia;  indeed,  it  is  a  wise  precaution  to 
employ  this  mydriatic  from  the  beginning  of  the  disease.  Eserin  has 
also  been  recommended,  or  the  combined  action  of  eserin  and  atropin, 
obtained  by  using  the  former  drug  during  the  daytime  and  the  latter 
at  night.  In  the  majority  of  instances  atropin  will  secure  the  best 
results.  Iodoform  freely  dusted  upon  the  ulcer  is  of  service;  also  the 
other  measures  recommended  for  the  control  of  infected  corneal  ulcers 
(see  page  272).     Dionin  is  recommended  by  Darier. 

If  perforation  has  taken  place,  excision  of  the  prolapsed  iris,  some- 
times advised,  is  not  without  danger,  as  this  procedure  may  open  a 
way  for  the  entrance  of  infecting  material  to  the  deeper  structures  of 
the  eye.  The  final  outcome  of  the  case  will  depend  upon  the  extent  of 
corneal  involvement  and  the  ultimate  treatment  of  the  remaining 
leukoma,  staphyloma,  or  shrunken  ball  will  require,  according  to 
circumstances,  iridectomy,  abscission,  evisceration,  or  enucleation. 

Often  the  patients  are  debilitated,  and  supporting  treatment  is  indi- 
cated, namely,  quinin,  iron,  and  strychnin.  If  there  is  constipation, 
calomel  and  saline  laxatives  should  be  administered.  The  pain, 
which  is  often  severe,  may  be  allayed  with  morphin  or  opium.  In 
place  of  morphin,  codein  may  be  employed.  It  is  a  mistake,  in  the 
serious  forms  of  this  disease,  to  depend  alone  upon  local  measures. 

The  treatment  of  a  chronic  conjunctivitis,  the  sequel  of  an  acute 
attack,  depends  upon  the  degree  of  thickening  in  the  mucous  mem- 
brane, but  is  usually  best  managed  by  careful  exposure  of  the  thick- 
ened conjunctiva  and  applications  of  nitrate  of  silver,  tannin  and 


220 


DISEASES    OF   THE    CONJUNCTIVA 


glycerin,  and  the  occasional  use  of  the  alum  or  sulphate  of  copper 
stick.  A  collyriuin  of  boric  acitl,  bichlorid  of  mercury,  or  sulphate  of 
zino  may  bo  used. 

Prophylaxis. — Patients  suffering  from  gonorrhea  should  be  warned 
not  only  of  the  great  danger  of  infecting  their  own  eyes,  but  the  eyes 
of  those  around  them.  Inasmuch  as  a  very  minute  quantity'  of 
urethfal  discharge,  and  even  where  this  is  the  product  of  a  chronic 
disease — gleet,  for  example — may  produce  acute  conjunctivitis,  these 
precautions  become  the  more  necessary. 

As  usually  one  eye  alone  is  affected,  it  is  a  matter  of  great  impor- 
tance to  secure  the  other  eye  from  contact  with  the  secretions.  This 
may  be  done  by  sealing  it  with  an  antiseptic  bandage,  the  edges  of 
which  are  made  tight  by  fastening  along  them  strips  of  gauze  painted 
with  floxil)lo  collodion,  or  by  the  application  of  Buller's  shield.  The 
latter  consists  of  a  watch-glass  fitted  in  a  square  piece  of  rubber  adhe- 
sive plaster,  which  is  carefully  applied  to  the  brow,  temple,  lower 
margin  of  the  orbit  and  nose,  and  should  be  secured  with  additional 
strips  to  prevent  the  entrance  of  discharge.'  The  inner  margin  should 
be  sealed  with  collodion,  as  a  contamination  is  most  likely  to  occur  at 

this  point,  and  inefficient  application 
increases,  rather  than  diminishes,  the 
danger. 

All  the  precautions  which  have  been 
urged  with  regartl  to  the  care  of  con- 
junctivitis neonatorum  apply  with  equal 
and  even  greater  force  to  the  present 
disease.  In  a  number  of  instances  the 
eyes  of  the  surgeon  or  nurse  in  attend- 
ance have  been  infected. 

Metastatic  Gonorrheal  Conjuncti- 
vitis- (doiiorrhcal  Kpibulhiiri  'onjunctiritis 
— Hccrfordt). — This  is  an  inflammation 
of  the  mucous  meml)rane  of  the  eye  due 
to  the  gonococcus  which  is  carrietl  from 
tlie  urethra  to  the  conjunctiva  through 
the  mctlium  of  the  circulation;  or  it  may 
1)('  caused  by  the  goiiotoxiii.  According 
to  W.  Gordon  M.  Byers,  whose  definition  has  just  been  (juoted,  it  may 
occur  as  the  initial  symptom  of  a  generalized  infection,  appear 
sinmltaneously  with  the  other  manifestations— for  example,  arthritis 
— follow  the  outbreak  of  inflammatoiy  symptoms  elsewiiere  located, 
or  be  the  only  expression  of  a  systemic  gonorrhea. 

The  disease  is  ahiiost  iM\'aiMal>l\'  liilaleial.  is  more  coimnon  in  men 


Fig.  105 


-.Application 
shield. 


f  Bill 


'  Care  .should  be  tiikcii  to  piuvidf  :i  wntcli-nljiss  of  tiic  onliiiMry  form,  not  one 
with  a  coiK'iivc  center. 

''Some  .siirneoriH  apply  tiie  nnme  (loiiorrhial  ophthiihiiia  to  this  afTeetion,  and 
reserve  the  term  iionturh'ul  runjiinrtivitis  for  tlie  disea.se  whieh  is  caused  l)y  a 
specific  urethral  di.scharne. 


CROUPOUS   OR   PSEUDOMEMBRANOUS   CONJUNCTIVITIS       221 

than  women,  and  resembles  a  catarrhal  conjunctivitis  with  some 
swelling  of  the  mucous  membrane  and  redness  of  the  lids.  Small 
ulcers  of  the  cornea  may  form.  According  to  Heerfordt,  it  may 
assume  the  form  of  phlyctenular  conjunctivitis.  Iritis,  iridocyclitis, 
and  uveitis  may  follow  this  inflammation,  just  as  they  may  be  associ- 
ated with  gonorrheal  rheumatism.  Endogenous  gonorrheal  keratitis, 
occurring  before  or  after  arthritis,  has  also  been  described,  but  the 
etiologic  relation  of  gonorrhea  in  this  regard -is  doubtful  (Elschnig). 
Relapses  of  metastatic  gonorrheal  conjunctivitis  occasionally  occur; 
the  average  duration  of  the  disease  is  about  two  weeks.  The  diagnosis 
depends  upon  the  presence  of  gonorrhea,  the  absence  of  the  gonococcus, 
and  the  ordinary  bacteria  of  conjunctivitis  in  the  secretion. 

The  treatment  of  this  affection  demands  the  same  remedies  useful 
in  ordinary  conjunctivitis.  Heerfordt  advises  massage  with  an  oint- 
ment of  yellow  oxid  of  mercurj^  and  a  lotion  of  copper  sulphate  (0.25 
per  cent.). 

Non=specific  Purulent  Conjunctivitis. — Purulent  conjunctivi- 
tis, not  gonorrheal  in  origin,  may  be  caused  by  the  secretion  of  diph- 
theritic conjunctivitis  and  by  trachoma.  As  has  been  noted,  the 
manifestations  of  Koch-Weeks'  bacillus  conjunctivitis  and  pneu- 
mococcus  conjunctivitis  are  not  infrequently  so  violent  and  the 
secretion  so  profuse  and  purulent  that  they  might  be  classified  among 
purulent  inflammations  of  the  conjunctiva.  (See  also  page  203.) 
It  should  further  be  remembered  that  a  catarrhal  conjunctivitis,  by 
neglect  or  injudicious  external  applications — for  example,  poultices — 
may  be  aggravated  into  an  inflammation  in  all  particulars  resembling 
gonorrheal  conjunctivitis.  Infection  from  the  nares  and  pneumatic 
sinuses  can  also  cause  severe  inflammation  of  the  conjunctiva,  associ- 
ated with  much  purulent  discharge.  The  treatment  is  exactly  that 
which  has  been  described  in  connection  with  other  forms  of  acute 
conjunctivitis.  The  best  results  follow  the  free  irrigation  of  the 
conjunctival  sac  with  a  saturated  solution  of  boric  acid  or  bichlorid  of 
mercury  (1:10,000),  or  mercurochrome  (one  per  cent.)  and  the  use  of 
argyrol,  protargol,  and  nitrate  of  silver  in  the  usual  manner.  If  prop- 
erly treated,  corneal  complications  are  uncommon. 

Croupous  or  Pseudomembranous  Conjunctivitis  {Plastic, 
Membranous  Conjunctivitis). — Of  this  disease,  two  varieties  may  be 
considered.  The  first  is  an  inflammation  of  the  conjunctiva,  character- 
ized by  a  soft,  usually  painless  swelhng  of  the  lids,  a  membranous 
exudation  upon,  not  within,  the  conjunctiva,  and  a  scant}-,  seropuru- 
lent  discharge. 

Causes. — The  affection  in  its  pure  form  is  rare,  the  majority  of 
cases  occurring  in  early  life — i.  e.,  between  first  haK  year  and  the 
seventh  year.  The  transmission  of  the  disease  from  one  eye  to  another 
has  not  been  established;  no  definite  cause  is  known,  although  for- 
merly an  endeavor  was  made  to  bring  it  into  relation  with  scrofula  and 
eczema.  Patients  affected  may  at  the  same  time  be  suffering  from  a 
croupous    inflammation    of    the    respirator}^    tract.     Some    authors 


222  DISEASES    OF   THE    CONJUNCTrV'A 

regard    the    affection    as    a    mild    diplitlieria.     Xon-virulent    Lofiler 
bacilli,  staphylococci,  and  diplococci  have  been  found  in  the  secretion. 

Symptoms. — The  symptoms  of  the  first  variety  of  croupous  con- 
junctivitis begin  with  an  acute  inflammation  of  the  conjunctiva, 
succeeded  by  swelling  of  the  lids,  which  remain  soft  and  pliant,  and 
usuallj'  not  painful  to  the  touch.  In  a  few  days  there  is  a  deposit 
of  a  (characteristic  false  membrane  composed  of  coagulated  fibrin, 
rather  translucent  and  porcelain-like  in  appearance,  beginning  upon 
the  retrotarsal  folds,  coating  the  inner  surfaces  of  the  lids,  but 
not  invading  the  bulbar  conjunctiva.  It  may  readily  be  removed 
without  loss  of  the  conjunctival  tissue,  and  shows  beneath  a  granular 
and  somewhat  bleeding  surface.  It  is  quickly  reproduced.  The 
cornea,  except  in  severe  cases,  escapes. 

Healing  takes  place  in  from  ten  to  thirty  daj^s,  except  in  those 
instances  where  the  membrane  is  formed  again  and  again,  and  the 
course  of  the  disease  may  continue  for  months  and  even  years,  con- 
stituting the  recurring  form  of  pseudomembranous  conjunctivitis. 
Such  recurring  membranous  conjunctivitis  has  been  observed  appar- 
ently as  a  complication  of  er3^thema  multiforme  and  has  lasted  for  \'ears 
(Stark).  A  similar  observation  has  been  made  by  the  author  in  the 
case  of  a  young  woman,  but  the  exact  nature  of  skin  disease  with 
which  the  recurring  conjunctival  membrane  formation  was  at  first 
associated  was  not  determined. 

Diagnosis. — The  disease  may  be  confounded  with  conjunctivitis 
neonatorum  and  diphtheritic  conjunctivitis.  From  the  former  it  is 
distinguished  by  the  absence  of  profuse  purulent  discharge  and  the 
age  of  the  patient;  from  the  latter,  by  the  soft  swelling  of  the  lids,  the 
superficial  character  of  the  membrane,  and  absence  of  virulent  Klebs- 
Lofflor  bacilli. 

Treatment. — This  should  include  the  frequent  removal  of  the 
discharge  with  a  solution  of  chlorid  of  sodium  or  chlorate  of  potash, 
and  later  the  cautious  use  of  nitrate  of  silver  (Knapp),  or  of  argyrol 
and  protargol.  As  in  manj^  instances  it  is  difficult  to  exclude  diph- 
theritic infection,  the  administration  of  diphtheria  antitoxin  should 
be  ordered  in  doubtful  cases.  Stark  obtained  the  most  satisfactory 
results  with  a  1  per  cent,  solution  of  sulphate  of  (luinine. 

The  second  variety  of  membranous  conjunctivitis  is  due  to  strepto- 
cocci, is  rapid  in  development,  and  is  associated  with  swelling  of  the 
lids  and  much  discharge,  and  may  quickly  destroy  the  cornea.  It 
occurs  in  children  in  association  with  measles,  scarlet  fever  and 
influ(!nza;  but,  according  to  Morax,  may  appear  indepiMuhMitly  of 
febrih;  complications  and  may  accompany  impetigo.  The  prognosis 
is  most  unfavorable  not  only  in  relation  to  eyesight,  but  also  in  relation 
to  life.  The  disease  is  often  mistaken  for  tliphtheritic  conjunctivitis 
(it  is  sometimes  called  .strt'ptcH-occus  diphtheria  of  the  coujunctira). 
Microscopic  examination  will  decide  the  diagnosis,  'i'he  treatment 
aln^ady  detailed  is  indicated.  According  to  Axenfeld  tlie  use  of 
streptococcal  serum  is  advisable. 


DIPHTHERITIC    CONJUNCTIVITIS  223 

Memhrane-forming  conjunctivitis,  not  strictly  classifiable  with 
either  of  the  foregoing  types,  occurs  as  an  intercurrent  condition  in 
several  varieties  of  conjunctivitis — for  example,  in  gonorrheal  conjunc- 
tivitis, pneumococcus  and  Weeks'  bacillus  conjunctivitis,  influenza 
conjunctivitis,  trachoma,  and  exanthematous  conjunctivitis.  Mem- 
brane may  also  form  in  the  conjunctiva  as  the  result  of  chemic, 
mechanic,  and  thermic  irritants.  It  is  especially  noteworthy  after 
certain  injuries  of  the  conjunctiva — for  instance,  lime-burns. 

Diphtheritic  Conjunctivitis. — The  deep-seated  or  necrotic  vari- 
ety of  this  disease  is  characterized  by  a  board-like,  very  painful 
swelling  of  the  lids,  a  scanty  seropurulent  or  sanious  discharge,  and 
exudation  within  the  layers  of  the  tarsal  conjunctiva,  which  spreads 
to  the  ocular  conjunctiva,  and  by  pressure  destroys  the  nutrition  of 
the  cornea. 

Causes. — In  addition  to  the  Klebs-Loffler  bacilli,  which  cause 
the  disease,  other  micro-organisms,  for  example,  streptococci,  staphy- 
lococci, and  non-virulent  xerosis  bacilli,  are  usually  present  in  the  dis- 
charge (Uhthoff).  The  disease,  which  is  communicable,  may  originate 
from  a  similar  case,  or  arise  in  the  course  of  a  purulent  conjunctivitis. 
It  has  occurred,  though  rarely,  with  conjunctivitis  neonatorum.  At 
times  it  appears  in  connection  with  eczema  of  the  face  and  borders  of 
the  lid,  and  is  an  occasional  accompaniment  of  some  acute  illness,  for 
example,  scarlet  fever  or  measles,  the  diphtheritic  tj^pe  of  the  inflam- 
mation being  ingrafted  upon  the  conjunctiva.  The  disease  has  been 
seen  during  epidemics  of  diphtheria,  and  may  be  part  of  a  process  which 
passes  from  the  nose  to  the  conjunctiva,  or  may  be  due  to  direct  inocu- 
lation with  the  diphtheritic  poison. 

It  is  commonest  between  the  ages  of  two  and  eight,  and  is  unusual  in 
young  infants.  In  certain  localities  in  the  south  of  France  and  the 
north  of  Germany  the  disease  was  formerly  frequent.  It  is  usually 
stated  that  the  disease  is  comparatively  rare  in  America  and  England  ; 
but  Sydney  Stephenson  records  a  percentage  of  1.25.  This  author 
regards  conjunctival  diphtheria  and  croupous  conjunctivitis  as  one  and 
the  same  disease. 

S3anptoms. — The  patches  appear  in  a  discrete  or  confluent  form: 
the  lids  are  swollen  with  a  characteristic,  painful,  board-like  hardness. 
The  false  membrane  is  of  a  dull,  grayish  appearance,  and  is  torn  off 
with  difficulty,  and  carries  with  it  parts  of  the  conjunctiva.  If  the 
process  is  deep,  the  subjacent  structure  is  pale,  infiltrated,  and  when  cut 
into  may  be  anemic  and  lardaceous.  If  the  diphtheritic  inflammation 
has  been  ingrafted  upon  a  case  of  purulent  conjunctivitis,  the  abundant 
secretion  ceases,  or  becomes  irritating  and  sanious. 

Sloughing  of  the  cornea  is  almost  inevitable  in  severe  cases,  and 
rapid  destruction  of  this  membrane  may  take  place  in  twenty-four 
hours;  even  in  mild  cases  ulcers  may  be  expected. 

Restlessness,  fever,  alimentary  derangements,  and  nervous  phe- 
nomena are  usual  constitutional  disturbances,  and  the  disease  may  be 
followed  by  loss  of  knee-jerk  and  paresis  of  various  parts  of  the  body. 


224  DISEASES    OF    THE    CONJUNCTIVA 

Albumin  may  be  present  in  the  urine,  and  occasionally  diphtheritic  con- 
junctivitis proves  to  be  fatal  (Stephenson). 

Diagnosis  and  Prognosis.— This  disorder  is  distin^;uished  from  the 
previous  disease  b\'  tlie  characteristic  board-like  infiltration  of  the  lids, 
by  the  situation  of  the  membranous  exudation  within  the  tissue  itself 
and  by  the  bacterioloj^ic  examination,  and  has  nothing  in  common  with 
the  flakes  of  false  membrane  sometimes  .seen  in  purul(Mit  conjunctivitis. 
The  prognosis,  as  may  have  been  inferred,  is  unfavorable,  although 
with  modern  treatment  more  cases  are  cured  without  impairment  of 
vision  than  formerly  was  possible.  Occasionally^  even  if  the  diph- 
theritic membrane  is  only  slightly  developed,  rapid  necrosis  of  the 
cornea  ensues. 

Treatment. — The  eyes  should  be  frequently  cleansed  with  warm 
boric  acid  solution  or  bichlorid  of  mercury  solution  (1:  8000)  and  atro- 
pin  drops  should  be  instilled.  Iodoform  salve  (or  powder)  may  be 
freely  applied  within  the  conjunctival  sac;  indeed,  vaselin  itself  is  effi- 
cient in  these  circumstances. 

Internally,  quinin,  iron,  and  mercury  have  been  recommended; 
but  the  greatest  rehance  should  be  placed  upon  diphtheria  antitoxin, 
which  should  be  promptly  administered  exactly  as  it  is  in  ordinary 
faucial  diphtheria.  At  the  first  dose,  1500  to  2000  units  of  antitoxic 
serum  maj^  be  injected  into  the  lateral  abdominal  wall,  and  repeated 
in  ten  or  twelve  hours,  according  to  the  severity  of  the  symptoms. 

The  sound  eye  may  be  covered  with  a  bandage  or  Duller 's  shield. 
The  patient  should  be  isolated. 

In  addition  to  the  deep-seated,  necrotic  variety  of  chphtheria  of  the 
conjunctiva,  the  disease,  according  to  Uhthoff,  Sourdille,  Elschnig.  and 
Morax,  may  assume  a  benign  aspect  and  a  superficial  pseudomem- 
branous form.  Why  virulent  diphtheritic  bacilli  sometimes  cause  a 
superficial  and  .sometimes  a  deep  interstitial  type  of  the  affection  has  not, 
according  to  Uhthoff  and  Coppez.  been  determined.  The  former  au- 
thor also  describes  a  simple  catarrhal  conjunctivitis  in  association  with 
diphtheritic  bacilli. 

Phlyctenular  Conjunctivitis  {Phliictcitular  Ophthalmia:  Scrofu- 
lous Ophthalmia;  Kczenia  of  the  Conjanctica). — This  is  a  form  of  in- 
flammation of  the  conjunctiva,  characterized  by  the  appearance  of  one 
or  more  grayish  elevations,  situated  chiefly  upon  its  bulbar  portion  in 
the  immediate  vicinity  of  the  cornea.  Less  frequently  the  jihlyctenules 
appear  upon  the  tarsal  conjunctiva,  those  on  the  lower  lid  i)eing  of 
firmer  consistence  tiian  those  on  the  bull)ar  conjunctiva  (Schiele). 

Causes. — The  disease  is  believed  to  be  of  constitutional  origin,  and 
its  sul)jects  are  often  tuberculous  and  badly  nourished  children. 
lOrrors  of  diet,  unwholesome  foods,  and  the  abuse  of  tea  and  coffee  act 
as  predisposing  causes.  It  oftcMi  follows  the  exantluMuata,  ('specially 
measles.  Infectious  rhinitis  is  always  present,  and  u.sually  the  sub- 
maxillary and  cervical  glands  are  swollen,  and  there  is  ecziMua  of  the 
lip  and  nares.  Theic  is  a  distinct  clinical  association  between  this  dis- 
ease ami  eczema.     It  is  possiijle  that  the  active  micro-organism  is  the 


II 


VERNAL   CONJUNCTIVITIS  225 

Staphylococcus  pyogenes  aureus  or  albus,  which  is  found  beneath  the 
epithelium  of  the  affected  conjunctiva,  but  an  endogenous  origin  of  the 
disease  cannot  be  wholh'  excluded.  That  the  disease  is  a  true  tubercu- 
losis is  disputed  by  Axenfeld. 

Symptoms. — The  disease  occurs  in  a  single  and  a  multiple  form; 
the  pimples  or  phlyctenulae  lie  near  the  corneal  margin  or  directlj^  upon 
it,  and  are  usually  from  1  to  3  mm.  in  diameter. 

If  the  elevations  are  large,  yellow,  and  contain  purulent  material, 
the  disease  has  been  called  pustular  ophthalmia. 

In  any  circumstances  it  is  accompanied  by  dread  of  light,  injected 
blood-vessels,  and  increased  lacrimation.     The    conjunctiva  may  be 
transparent,  or  the  disorder  associated  wth  a  mucopurulent  conjuncti- 
vitis.    After  the  exanthemata  this  asso- 
ciation is  common. 

In  the  multiple  form,  numerous  min- 
ute phh^ctenules  may  be  scattered  over 
the  entire  conjunctiva,  and  are  accom- 
panied by  decided  general  red  injection, 
irritation,  and  photophobia.  The  dis- 
order subsides  in  from  ten  days  to  two 
weeks. 

Treatment. — Locallv,  mild  antiseptic    „       ,«^     t,ui    .      i 

...  •    n      1      • "  CI        •  1       -f^^*^-    ^06. — Phlyctenular    conjunc- 

COllyna,  especially  lotions    of   boric   acid,  thitis  (ChUdren's  Hospital). 

are    useful.     ^luch    irritation    indicates 

atropin  drops  and  the  occasional  instillation  of  holocain  to  reheve  the 

photophobia.     The  eyes  may  be  protected  by  colored  glasses. 

After  the  acute  symptoms  have  subsided  the  best  results  are  ob- 
tained by  introducing  the  j-ellow  oxid  of  mercury,  1  grain  to  1  dram 
(0.065-3.885  gm.),  into  the  conjunctival  sac  or  by  dusting  into  it 
calomel,  provided  the  patient  is  not  taking  iodidof  potassium,  otherwise 
a  reaction  between  the  potassium  iodid  in  the  tears  and  the  calomel 
occurs,  with  the  ultimate  formation  of  double  iodidS;  which  are  caustics 
(calomel  conjunctivitis).  Applications  of  borobismuth  ointment  to  the 
nasal  eczema  are  recommended  by  Schiele,  who  also  speaks  favorably  of 
such  antiseptic  powders  as  gallicin,  iodogallicin,  and  bismuth  oxyiodid 
tannate.  Linear  cauterization  of  the  fornix  has  been  advised  in  severe 
cases. 

An  excellent  regulation  treatment  is  a  mild  course  of  mercurial 
laxatives.  Simple  diet,  good  air,  exercise,  and  internally,  quinin,  iron^ 
arsenic,  and  cod-liver  oil,  complete  the  therapeutic  measures. 

Phlyctenular  conjunctivitis  is  so  closely  allied  to  phlyctenular 
keratitis  that  the  separation  of  the  two  affections  is  purely  artificial, 
and  this  account  is  a  preface  to  the  description  of  the  more  exact  cUs- 
position  and  relation  of  the  phh'ctenules,  which  appears  on  page  260. 

Vernal  Conjunctivitis  (Fruehjahr's  Catarrh,  S&emisch;  Phlyct(ma 
Pallida,  Hirschberg;  Periodic  Hyperplastic  Conjunctivitis,  Wicher- 
kiewicz;  Fibroma  of  the  Limbus;  Spring  Conjunctivitis). — This  form  of 
conjunctival  disease  is  characterized  by  photophobia,  stinging  pain. 


226  DISEASES    OF    THE    CONJUNCTIVA 

considerable  mucous  secretion,  the  formation  of  flat  granulations  in 
the  palpebral  conjunctiva,  and  a  hypertrophy  of  the  conjunctiva  sur- 
rounding the  limbus  of  the  cornea. 

Causes. — Definite  information  in  regard  to  the  cause  of  this  disease 
is  lacking.  It  is  possible  that  some  specific  micro-organism  exists 
which  has  not  yet  been  isolated.  Although  frequently  the  disorder 
returns  in  the  early  spring,  is  more  aggravated  during  the  summer  season 
and  subsides  in  the  fall  and  winter,  cases  may  occur  in  any  month  of 
the  year,  and  its  designation,  spring  catarrh,  is  not  a  good  one,  because 
the  affection  is  in  no  sense  a  catarrhal  one,  and  it  does  not  necessarily 
occur  in  the  spring.  Heat,  especially  dry  heat,  must  be  regarded  as  an 
exciting  factor,  even  though  it  is  not  the  sole  cause  of  the  disease. 

It  is  most  frequent  between  the  ages  of 
five  and  fifteen,  but  occasionally  occurs 
in  advanced  adult  life  and  in  very 
young  children,  even  those  but  a  few 
months  of  age.  According  to  Posey's 
^      _^_^^^_^  investigations,  it  is  more  frequent  in 

^^'^ilfcll^M' "  niales  in  the  proportion  of  85  to  15 

per  cent,  and  the  greater  liability  of 
the  male  sex  to  this  affection  is  con- 
FiG.  i07.-spring  conjunctivitis        g^^^  ^  observations.     It  may 

accompany  the  disease  known  as  hay- 
fever.  Some  writers  decline  to  consider  vernal  conjunctivitis  a  distinct 
disease,  but  look  upon  it  as  a  hypertrophic  form  of  chronic  conjunctivitis. 
In  a  few  instances  it  appears  to  be  hereditary,  and  Meyerhof  and  Gab- 
ri^lid^s,  describe  a  familial  type  of  vernal  conjunctivitis.  The  latter 
author  inclines  to  the  belief  that  spring  conjunctivitis  may  be  a 
manifestation  of  an  autointoxication  of  the  organism.  At  times  there 
appears  to  be  a  congenital  disposition  to  the  disease. 

Symptoms.^ — ^ There  are  three  varieties  of  this  disease^ — the  limbus, 
palpebral  and  mixed  forms.  The  affection  l)egins  like  an  ordinary  con- 
junctivitis and  is  almost  always  bilateral;  a  few  unilateral  cases  are  on 
record.  There  are  photophobia,  more  or  less  mucous  secretion,  cir- 
cumscribed pericorneal  injection,  and  the  formation  at  the  limbus  of 
small,  gray,  semitransparcnt  nodules,  which  swell  up  and  overlap  the 
edge  of  the  cornea.  Oceasionally  in  the  limbus  form  of  vernal  con- 
junctivitis large  vegetative  lesions  develop. 

The  conjunctiva  of  the  bulb  is  injecteil,  that  of  the  liiis  is  slightly 
thickened  and  of  a  dull,  pale  color,  as  if  brushed  over  with  a  thin  layer 
of  milk.  This  milky  film  or  "l)luish-milky"  surface  rcHex  is  one  of  the 
most  characteristic;  symptoms  of  th«'  disease,  and  may  be  observed 
before  the  granulations  appear  on  tiie  inner  surface  of  the  litis;  occa- 
sionally, even  in  typical  cases,  it  is  lacking.  When  the  granulations 
appear  in  typical  form,  they  cover  the  tarsal  conjunctiva,  are  flattened, 
aiui  contain  deep  furrows  between  tliem.  In  the  colored  race  tiiere  is  a 
brownish  pigmentation  of  the  scleral  base  of  the  hypcitropliicd  mas.sc8 
(Burnett). 


VERNAL   CONJUNCTIVITIS  227 

The  disease  may  be  distinguished  from  trachoma  by  the  flattened 
appearance  of  the  granulations,  the  absence  of  infiltration  and  pannus, 
and  the  history  of  recurrence  at  special  seasons  of  the  year.  Elschnig 
calls  attention  to  an  arrangement  of  the  blood-vessels  of  the  tarsal  con- 
junctiva which  he  considers  peculiar  to  spring  catarrh.  The  normal 
vascular  distribution  is  replaced  by  innumerable  small  vessels  arising 
perpendicular  to  the  conjunctival  surface.  Mixed  forms  of  spring 
catarrh  and  trachoma  have  been  described  (May,  Meyerhof). 

The  pathologic  histology  of  the  lesions  has  attracted  much  attention 
in  recent  years.  According  to  Axenfeld,  who  has  elaborately  investi- 
gated this  disease,  the  primary  lesions  arise  in  the  subconjunctival 
tissue,  followed  by  proliferation  of  the  epithelium.  An  accumulation 
of  plasma  cells  takes  place,  succeeded  by  a  homogeneous  sclerosis  of 
the  connective  tissue.  Elastic  tissue  is  abundant.  The  milky  appear- 
ance of  the  surface  of  the  conjunctiva  is  due  to  subepithelial  hyalin 
thickening.  Eosinophils  are  frequent  in  the  conjunctiva  and  occur 
in  large  numbers  in  the  secretion.  There  is  no  essential  difference 
between  the  tarsal  and  palpebral  manifestations  of  the  affection, 
unless  future  investigations  should  confirm  the  assertion  of  some  ob- 
servers that  in  the  bulbar  proliferations  the  epithelial  changes  take 
precedence. 

The  prognosis  of  the  disorder  is  not  unfavorable,  except  in  so  far 
as  relapses  are  concerned,  which  make  its  course  a  long  one,  sometimes 
lasting  from  eight  to  ten  years,  or  even  longer.  Usually  the  activity 
of  the  process  begins  to  subside  after  it  has  existed  for  six  or  seven 
years.     Slight  opacity  of  the  cornea  may  result. 

Treatment. — During  the  height  of  the  attack  the  eyes  may  be  pro- 
tected with  dark  or  yellow-tinted  glasses.  Cold  compresses  a!,  ord 
some  relief.  Weak  astringents  and  antiseptic  lotions,  such  as  have  been 
recommended  for  ordinary  conjunctivitis,  are  useful.  The  application 
of  boroglycerid  to  the  everted  lid  is  sometimes  valuable,  and  the  sys- 
tematic use  of  a  preparation  of  suprarenal  extract,  or  of  adrenalin 
chlorid  (1  :  10,000),  to  which  a  1  per  cent,  solution  of  holocain  is  added, 
is  of  service.  Axenfeld  suggests  the  application  of  a  solution  of  sul- 
phate of  quinin,  and  Elschnig  advises  the  instillation  of  a  watery 
solution  of  ichthyol  (1  to  2  per  cent.).  Salicylic  acid  ointment  (1  per 
cent.)  is  recommended,  and  massage  with  yellow  oxid  ointment  may 
be  tried.  Electrolysis  has  been  employed,  and  brossage  has  been 
advised  by  L.  W.  Fox.  Exuberant  granulations  and  limbus  hyper- 
trophies may  be  excised.  According  to  Wicherkiewicz,  a  collyrium 
of  antipyrin  (10  per  cent.),  and  instillations  of  2  or  3  per  cent,  of 
protargol  are  efficient.  Fibrolysin,  as  suggested  by  Luedde,  is  a 
remedy  of  real  value:  It  is  used  as  follows:  a  2  per  cent,  solution  of 
holocain  having  been  instilled,  the  lid  is  everted  and  painted  with  a 
yi  per  cent,  solution  of  nitrate  of  silver,  followed,  after  its  neutrali- 
zation, by  an  application  of  fibrolysin  by  means  of  a  cotton-wound 
probe,  or  the  fibrolysin  may  be  be  dropped  into  the  eye.  These  applica- 
tions may  be  made  every  other  day.     In  the  intervals  the  patient  should 


228  DISEASES    OF    THE    CONJUXCTIVA 

use  a  sulphate  of  zinc  lotion  (^i  per  cent.)  freely.  Starr,  in  Buffalo, 
and  Allport,  in  Chicajiio,  have  reconiniended  the  j-rays  in  the  same 
manner  as  they  are  api)lied  in  trachoma,  and  have  reported  favorable 
results.  Radium  treatment  of  vernal  conjunctivitis  is  most  effective. 
Shumway,  who  has  well  studied  the  influence  of  this  agent  in  this 
regard  and  who  has  reported,  among  others,  cases  from  the  author's 
service  in  the  University  Hospital  atlvises  the  following  tcn-hnic: 
the  eye  being  cocainized  and  the  upper  lid  everted,  the  radium  element 
(35-50  mg.)  is  applied  to  the  exposed  surface,  enclosed  in  an  aluminium 
tube  5  mm.  in  thickness.  The  application  may  be  made  at  intervals 
of  about  four  weeks.  There  is  always  some  reaction;  the  lashes  are 
apt  to  drop  out,  but  in  time  are  reproduced.  There  is  some  evidence 
to  show  that  the  internal  administration  of  arsenic  is  of  advantage. 
Associated  intranasal  inflammation  should  be  treated.  Change  from 
a  warm  to  a  cool  climate  is  of  service. 

Follicular  Conjunctivitis  (FoUicnIar  Ophthalmia;  Coujuncdritis 
FoUiculan's  Simplex;  Folliculosis;  ''School  Follicles''). — This  affection 
is  characterized  by  the  presence  of  small  pinkish  prominences  in  the 
conjunctiva,  for  the  most  part  in  the  retrotarsal  folds,  and  usually 
arranged  in  parallel  rows.  The  descriptive  term  "conjunctivitis" 
maj'  be  applied  to  the  affection  if  the  signs  of  inflammation  are  asso- 
ciated with  it;  if  the  latter  are  absent,  the  term  folliculosis  of  the  con- 
junctiva is  more  appropriate. 

Causes. — The  disease  arises  unciler  the  influence  of  poor  hygienic 
sunouiuiings,  especially  in  pauper  schools,  where  it  may  appear  as  an 
aggravated  epidemic,  but  it  is  frequently  seen  in  comparativ(>iy  mild 
form  especially  among  children  during  their  school  years,  particularly  if 
they  are  the  subjects  of  anemia  and  chlorosis;  adenoids  and  granular 
pharyngitis  are  commonly  present.  Indeed,  in  so  large  a  ptMcentage 
of  school  children  can  tumefaction  of  the  conjunctival  lymph-follicles  be 
found  that  the  name  school-folliciilosis  has  been  suggested  by  Cireeflf. 
Evidently  lefractivc  errors  are  an  exciting  cause  of  many  of  these 
cases.  Enlargement  of  the  follicles  may  also  be  caused  by  local  irri- 
tants and  some  medicaments — for  example,  atropin  (se(>  page  244). 

Much  difference  of  opinion  exists  as  to  whether  folliculosis  should 
be  placed  in  a  separate  category  from  trachoma,  or  whether  it  should 
be  regarded  as  an  early  stage  of  the  latter  disease.  Although  transi- 
tional forms  apparently  exist,  the  evidence,  clinically  at  least,  warrants 
the  l)clicf  that  this  affection  is  distinct  from  trachoma,  because 
folliculosis  o(;(;urs  where  trachoma  is  unknown,  and  becau.'^e  the  folli- 
cles disappear  without  leaving  a  trace  of  their  existence  or  producing 
scar  tissue  in  the  conjunctiva.  Histologically,  however,  there  is  no 
decisive  difference  ix'tween  fresh  follicles  ami  fresh  trachoma  botlies.  It 
would  seem,  as  (Ireeff  insists,  that  folliculosis  may  arise  under  the  in- 
fluence of  various  excitants,  and  in  this  sense  is  ;i  symptom  and  not  a 
(hstinct  disease. 

Symptoms.  The  children  for  it  mostly  (tccurs  in  eliilihen  and 
joiiiig  people     complain  of  slight  lii-eail  of  light  and  inability  to  con- 


il 


TRACHOMATOUS    CONJUNCTIVITIS  229 

tinue  at  close  work,  and  inspection  reveals  numerous  round  elevations 
in  the  conjunctiva,  chiefly  along  the  fornix,  which  are  tumefied  Ij'm- 
phatic  follicles,  that  is,  they  represent  an  enlargement  or  elaboration 
of  the  normal  lymphoid  follicles,  due  to  an  irritant,  perhaps  chemical 
in  nature.  The  color  of  the  follicles  varies  from  nearly  white  to  a 
decided  pink.  After  their  disappearance  the  conjunctiva  regains  its 
natural  state. 

If  with  the  enlarged  follicles  inflammatory  symptoms  are  combined, 
the  disease  is  a  true  follicular  conjunctivitis;  the  lids  are  swollen, 
reddened,  and  their  margins  streaked  with  secretion,  which,  at  first 
thin,  may  become  more  purulent  and  quite  abundant.  In  certain  cir- 
cumstances the  disease  resembles  the  condition  termed  ''swelling  with 
catarrh"  (see  page  207),  except  that  the  development  of  the  follicles  is 
much  more  evident.  The  inflammatory  form  of  the  affection  may 
assume  a  more  chronic  type,  with  special  development  of  the  follicles  in 
the  fornices,  and  only  secretion  enough  to  stick  together  the  lids  in  the 
morning.  Often  an  acute  mucopurulent  conjunctivitis  precedes  the 
development  of  the  follicles,  that  is  they  are  evident  after  its  subsidence. 

Diagnosis. — The  disorder  can  usuallj^  be  distinguished  from 
trachoma  by  observing  that  the  small  bodies,  which  are  benign  follicles, 
are  neither  so  large  as  trachoma  granulations  nor  so  highl}^  colored  as 
hypertrophied  papillae;  that  they  are  confined  to  the  fornices  and  are 
not  seen  on  the  plica  or  bulbar  conjunctiva;  that  the  mucous  membrane 
is  not  affected  more  deeply  than  the  lymphatic  follicles;  and  that 
cicatricial  changes  are  not  present.  Border-line  cases,  however,  occur, 
which  are  difficult  to  classify  and  of  which  no  one  has  ever  yet  suc- 
ceeded in  writing  a  description  upon  which  an  entirely  satisfactory 
diagnosis  could  be  made. 

Prognosis. — This  is  good  in  so  far  as  the  fate  of  the  mucous  mem- 
brane is  concerned,  but  the  disorder  is  troublesome  and  will  often  last 
for  months,  and  under  imperfect  hygienic  surroundings  and  in  crowded 
asylums,  may  prove  to  be  a  stubborn  affection. 

Treatment. — The  usual  antiseptic  and  astringent  lotions  are  in- 
dicated and  applications  of  boroglycerid  or  of  tannin  and  glycerin  are 
useful.  A  salve  of  H  grain  (0.0324  gm.)  of  sulphate  of  copper  to  the 
dram  (3.885  gm.)  of  vaselin  has  been  highly  extolled.  If  there  is 
much  secretion,  the  usual  treatment  of  conjunctivitis  is  required 
especiall}'-  silver  and  its  various  salts. 

Refractive  error  should  be  corrected  because  ametropia  aggravates 
the  disorder.  In  stubborn  cases,  and  in  those  where  the  follicular 
eruption  is  elaborate,  especially  in  asylums  and  schools,  expression  of 
the  swollen  follicles  with  suitable  forceps  should  be  performed  (see 
page  686). 

Trachomatous  Conjunctivitis  {Trachoma;  Granular  Lids;  Granu- 
lar Conjunctivitis;  Egyptian  Ophthalmia;  Military  Ophthalmia). — 
This  is  a  disease  of  the  conjunctiva  in  which  this  membrane  loses  its 
smooth  surface,  owing,  to  an  inflammatory  infiltration  of  its  adenoid 
layer,  associated  with  the  development  of  follicles  ("granulations") 


230  DISEASES    OF   THE    CONJUNCTIVA 

and  enlargement  of  the  so-called  papillary  layer.  After  absorption  and 
metamorphosis  of  the  inflammatory  material,  cicatricial  changes  are 
found. 

Causes  and  Distribution. — Formerly  it  was  the  custom  to  separate 
this  disease  into  two  forms — acute  granulations,  or  acute  granular 
conjunctivitis,  and  chronic  granulations,  or  chronic  granular  conjunc- 
tivitis, and  certain  systematic  writers — ^for  example,  Saemisch — con- 
tinue this  distinction.  The  author  is  in  agreement  with  those  who 
maintain  that  the  so-called  acute  trachoma,  at  least  in  the  majority  of 
cases,  represents  an  admixture  of  ordinar}-  trachoma  and  acute  con- 
junctival catarrah.  An  attack  of  acute  conjunctivitis  may  precede 
the  development  of  trachoma.  According  to  MacCallan,  in  Egj^pt, 
the  acute  symptoms  are  most  often  caused  by  the  Morax-Axenf eld  bacil- 
lus, the  Koch-Weeks  bacillus,  and  the  gonococcus.  Gree.V,  however, 
seems  to  have  proved  by  inoculation  that  there  is  an  acute  trachoma 
which  may  develop  in  a  few  days. 

Trachoma  may  arise  apparently  under  the  influence. of  poor  hy- 
gienic surroundings,  and  in  institutions  where  the  inmates  are  crowded 
together  the  disease  may  readily  spread. 

Distribution. — The  dissemination  of  trachoma  in  Europe  became 
noteworthy  after  the  return  of  Napoleon's  soldiers  from  Egypt,  in- 
asmuch as  75  per  cent,  of  them  had  been  infected.  They  came  | 
repeatedly  in  contact  with  each  other  and  with  the  civil  population,  i 
and  thus  spread  the  disease,  often  in  epidemic  virulence.                                   | 

Hence  in  the  early  portion  of  the  nineteenth  century  trachoma  | 

found  in  civil  life  a  favorable  soil  for  its  dissemination  in  jails,  asylums  f 

and   wherever  inha])itants  of   the   poorer   classes   dwelt   together  in  , 

close  contact,  and  at  this  time  in  many  pauper  schools  every  inmate 
was  affected.     The  acute  course  which  the  disease  manifested  at  this  ; 

period  of  its  history  was  doubtless  due  to  mixed  infection  and  such 
epidemics  have  in  great  measure  disappeared.  Nevertheless,  tra- 
choma remains  endemic  in  many  lands;  it  is  indeed,  a  world  disease. 
It  is  most  frequent  in  Arabia  and  Palestine,  and  in  Egypt  it  is  gen- 
eralized, fully  95  per  cent,  of  the  native  population  being  afifected  (Mac- 
Callan).  Trachoma  is  endemic  in  Syria,  Persia,  Central  Asia,  China 
and  Japan.  Exceedingly  prevalent  in  Eastern  Europe,  especially  in 
Gallipoli,  Poland,  Lithuania,  Russia,  Hungary  and  certain  districts  in 
Prussia,  it  is  noteworthy  that  Jews  of  inferior  social  grade  are  prone  to 
be  affected.  It  is  frequent  among  Italians  of  the  lower  orders,  espe- 
cially in  the  south  of  Italy.  In  England  "trachoma  is  an  alien  disease, 
imported  l)y  aliens,  pi'opagated  l)y  aliens  and  handed  on  to  the  native 
population  by  aliens"  (Parsons);  in  Ireland  it  is  conunon  among  the 
poorer  classes. 

The  menace  of  trachoma  on  our  own  shores  is  one  of  tlu*  serious 
problems  of  our  Innnigration  Officers.  It  is  common  among  native 
Americans  in  certain  portions  of  our  own  country,  moreover,  in  sm'ere 
and  dcslruclive  manifestation,  especially  in  dclinite  areas  in  Illinois, 
in   the  moiitit;iiiious  regions  of   Kentucky  ;iii(l   West    N'irginia,  and  is 


TRACHOMATOUS    CONJUNCTIVITIS  231 

particularly  noteworthy,  according  to  the  researches  of  Dr.  Stucky  and 
of  Dr.  John  McMullen,  of  the  United  States  Pubhc  Health  Service,  in 
the  neighborhood  of  the  junction  of  Kentucky,  Tennessee  and  the 
Virginias.  In  States  where  high  winds  prevail  and  there  is  much 
irritating  alkaline  dust,  e.  g.,  in  Oklahoma,  Arkansas,  Texas,  Arizona 
and  New  Mexico,  trachoma  is  very  prevalent.  To  the  prevalence  of 
trachoma  among  the  Indians  of  our  country  much  attention  has  been 
paid,  with  encouraging  results. 

A  certain  racial  predisposition  to  trachoma  has  been  maintained, 
the  Mongolian  race  being  especially  liable;  but  throughout  Asia  the 
disease  is  no  respecter  of  race,  the  Aryan,  Semitic  and  Mongolian 
suffering  with  equal  frequency.  Although  the  negro  may  have  a 
certain  resistance  to  trachoma,  his  exemption,  at  one  time  insisted 
upon  by  Burnett  and  others,  is  certainly  not  correct,  as  is  shown  by 
Minor  and  White,  and  the  author  has  observed  a  number  of  cases  in  a 
large  experience  in  the  Philadelphia  General  Hospital,  although  he 
cannot  be  sure  that  these  negroes  were  of  pure  blood. 

A  climatic  predisposition  is  more  than  doubtful,  although  it  has 
been  found  that  dwellers  in  certain  regions  of  the  earth  where  the 
climate  is  damp  are  readily  affected.  While  it  has  been  maintained 
that  an  altitude  of  more  than  a  thousand  feet  confers  a  comparative 
immunity  fron^  the  disease  and  facilitates  its  cure,  and  while  this  may 
be  true  in  Switzerland  and  the  Tyrol,  certainly  in  our  own  country 
no  such  influence  of  altitude  is  evident.  D.  W.  White  has  found 
and  studied  the  disease  8000  feet  above  sea  level. 

Bacteriology  of  Trachoma. — Transference  of  the  morbid  material 
from  a  trachomatous  conjunctiva  to  another  eye  may  result  not  only 
in  a  purulent  conjunctivitis,  but  in  a  disease  like  the  one  from  which  it 
came.  In  this  sense  the  disease  is  specifically  communicable  although 
the  affection  is  not  conspicuously  communicable  by  secretion  inocula- 
tion (Axenfeld).  There  is  no  proof  that  trachoma  is  caused  by  micro- 
organisms of  the  bacterial  group  or  by  blastomycetes.  Treacher 
Collins  has  suggested  that  the  disease  depends  upon  an  organism 
of  ultramicroscopic  dimensions.  Cohen  and  Noguchi  think  the  cause 
of  trachoma  is  a  non-identified  specific  virus. 

Halberstadter  and  von  Prowazek,  working  in  Java,  and  Greeff, 
Frosch,  and  Clausen,  in  Germany,  discovered  in  the  discharge  and 
follicle  contents  of  trachoma  very  small  granules,  resembling  diplo- 
bacteria.  They  are  surrounded  by  a  zone  (hence  called  by  Prowazek 
chlamydozoa) ,  and  occur  either  isolated  or  grouped  together  within 
the  cell  next  to  the  nucleus  (see  also  page  232).  They  increase  in 
number,  and  gradually  occupy  almost  the  entire  protoplasm  of  the 
cell  which  is  destroyed,  and  they  are  set  free  in  the  secretion.  Certain 
small  bodies  are  seen  in  the  protoplasm  of  the  cells  and  outside  of  the 
cells,  and  they  almost  always  accompany  the  "inclusions,"  and  are 
called  "Lindner's  initial  bodies."  The  Prowazek  bodies  are  found  in 
fresh,  untreated  trachoma,  less  easily  in  granular  conjunctivitis, 
of  long  standing.     Their  exact  nature  is  unknown,  although,  according 


232 


DISEASES    OF    THE    CONJUNCTIVA 


to  Axpnfeld.  they  probably  arc  neither  cell-products,  metamorphosed 
gonococci  (Herzog),  nor  the  products  of  mucoid  defeneration.  They 
are  so  seldom  present  in  other  conjunctival  disease  that  their  detection 
is  highly'  significant.  Their  absence,  however,  does  not  exclude 
trachoma.  They  are  usually  known  as  "Prowazek  or  Prowazek- 
Halberstiidter  bodies  or  corpuscles,"  and  they  have  also  been  found  in 
ophthalmia  neonatorum  (Heymann)  (see  page  216).  in  their  early 
stage  in  the  normal  conjunctiva,  and  in  some  forms  of  chronic  con- 
junctivitis (Erdmann). 

Pathology  and  Varieties  of  Trachoma. — The  pathognomonic 
appearance  and  essential  element  of  the  disease  trachoma  are  the 
"granulations,"  or  "trachoma  bodies,"  or  follicles.^ 


J^m:^ 


"OS" 


Fig.   108. — So-called  trachoma  bodies — epithelial  inclusions  (.\xeiifeld). 


Two  views  have  been  held — the  one  that  the  trachoma  bodies  have 
a  special  pathologic  character;  the  other  that  they  are  derived  from 
the  lymphatic  follicles,  which,  although  poorly  developed,  are  probably 
present  in  the  natural  human  conjunctiva,  and  some  authors  declare 
that  these  follicles  and  their  changes  originate  all  the  anatomic  and 
clinical  qualities  of  trachoma.  Although  it  may  not  be  possible  to  dis- 
tinguish in  the  early  stages  trachoma  bodies  from  enlarged  lymphatic 
follicles,  there  is  a  difference  in  the  nature  of  the  two  conditions,  and 
for  the  most  part  the  "unitarian  standpoint"  with  reference  to  tra- 
choma has  been  abandoned — that  is,  the  theory  that  all  follicles  in  the 
conjunctiva  represent  trachoma.  Certainly  so-called  "benign  ftillides" 
exist  which  disappear  without  a  I'esidue  of  lesions  (see  pag(^  228), 
and,  on  the  other  iiand,  an  infection  witii  follicular  formation  arises 
which  subsides  after  a  long  period  of  time  and  leaves  cicatrices  (see 
page  283).  Between  these  two  forms  arc  tiic  "border-line"  cai^es 
whicli  aic  dillicull  to  classify.  Treacher  Collins  suggests  that  in 
tiaclionia  thi-re  is  an   in\asion  <if  the  sulx-pitlielial   tissue  1)\-    micro- 

*  It  .should  lit"  rciiifiiihcrL'd  that  the  woril  "utaiiiiljitioiis"  refers  lo  tlicchanictor- 
istic  feiidiie  of  t nichoiiia,  and  not  to  siirf:ice  f^nmuliitions  which  Mi:iy  form  duriii>; 
the  course  of  the  diseiiHe.  Tht!  iVow.'izek  Ixxlies  jiie  .ulso  called  'trachoiu.a  hodies" 
by  some  authors,  for  oxaniple,  l)y  GreelT. 


TRACHOMATOUS    CONJUNCTIVITIS 


233 


organisms  which  have  penetrated  the  outer  defense  of  epitheHiim  and 
have  become  surrounded  by  a  new  formation  of  lymphoid  tissue.  The 
onset  of  trachoma  may  be  preceded  by  a  Koch- Weeks  bacillus  con- 


FiG.  109. — Trachoma  of  the  retrotarsal  fold;  a,  Follicle;  b.  diffuse  infiltration;  c,  Henle's 
gland  with  goblet-cells;  d,  lymph-vessel  filled  with  leukocytes  (  X  30)  (Holden). 

junctivitis  in  which  Prowazek  bodies  can  be  found.  Some  authors 
deny  that  trachoma  is  a  specific  disease,  believing  that  it  is  the  patho- 
logic expression  of  the  reaction  of  the  conjunctiva  to  various  irritants 
(Walker). 

The   following  clinical  vari-         "  -' 

eties  of  chronic  trachoma  have 
been  recognized  by  systematic 
writers: 

1.  Papillary  trachoma,  in 
which  the  trachoma  bodies  or 
follicles  are  sparselj'  present  or 
are  hidden  from  view  byhyper- 
trophied  conjunctival  papillae,  or, 
more  accurately,  pseudopapillae. 
The  blood-vessels  are  enlarged, 
and  there  is  marked  increase  in 
the  number  of  Ij-mphoid  cells. 
The  follicles  in  the  adenoid  layer 
lift  above  them  the  thickened 
epithelium.  This  form  is  some- 
times spoken  of  as  chronic  tra- 
choma.    (Fig.  110.) 

2.  Follicular  trachoma,  in 
which  the  presence  of  the  "fol- 
licles" or  trachoma  bodies  is 
the  chief  characteristic.  These 
bodies   are  round  collections  of 

lymphoid  cells  which  may  possess  an  incomplete  capsule,  and  which, 
as  before  stated,  are  elaborately  developed  in  the  adenoid  layer 
of  the  conjunctiva.     Some  authors  consider  follicular  conjunctivitis 


Fig.  110. — Chronic  trachoma  of  the 
papillary  type,  beginning  cicatrization 
(Medical  War  Manual,  No.  3). 


234 


DISEASES    OF    THE    CONJUNCTIVA 


(see  page  228)  a  variety  of  this  type.  Systematic  writers  have  dif- 
ferentiated the  following  cellular  elements  in  the  trachoma  foUicle: 
lymphocytes,  which  form  the  chief  constituent  of  the  peripheral  zone; 
mononuclear  leukocA'tes,  which  compose  the  chief  portion  of  the  folli- 
cle; phagocytes,  which  are  found  among  the  leukocytes;  and  certain 
accessory  elements — for  example,  multinuclear  cells,  etc.  Beneath  the 
follicles  are  dilated  lymph-vessels,  and  blood-vessels  may  extend  into 
the  follicles.  The  lymphadenoid  tissue  surrounding  the  follicles  is 
infiltrated  with  leukocytes.  Some  of  the  cells  of  the  follicles  are  dis- 
charged or  absorbed;  others  are  converted  into  connective-tissue  fibers, 
which,  by  their  contraction,  produce  the  changes  described  on  page  235. 


lip 


..-•.^f'' 


Fig. 


111. — Follicular    trachoma    (Medical 
War  Manual  No.  3). 


Fiu.  112. — Cicatricial  trachoma  and  pamius 
(Medical  War  Manual  No.  3). 


According  to  Parsons,  the  invariable  termination  of  trachoma  in  cica- 
trization is  brought  about  bj'^  absorption  of  the  contents  of  the  follicles 
and  proliferation  of  the  connective  tissue  of  the  conjunctiva,  it  being 
doubtful  if  theclementsof  the  folliclecaii themselves  f()rnifil)rc)us  tissue. 

In  one  form,  designated  by  Knapp  non-injlatiimatory  follicular 
trachoma,  the  spawn-like  granulations  develop  in  the  conjunctiva  with- 
out evidence  of  inflammation,  and  have  been  regarded  as  analogous  to 
nasopharyngeal  adenoid  liypertr()i)lues  (see  also  page  22S). 

'A.  Mixed  traclionia,  in  which  the  follicles  or  bodies  lie  among  hyper- 
trophied  and  inflamed  papilhc,  but  are  not  hidden  by  them.  This 
type  is  sometimes  described  as  diffuse  or  complicated  trachoma. 

4.  Sclero,si7i(j  trachoma,  in  which,  after  an  initial  stag(>  of  ordinary 
granulations,  leathery  (fibrous),  flattened  excrescen<'(>s  dexelop  in  the 
upper  tarsal  and  retrotarsal  conjunctiva. 

5.  Cicatricial  trachoma,  in  winch  atrophy  and  si-ar  tissue  are  mani- 
fest— "the  end  stage  of  uncured  cases"  (Knapp). 


TRACHOMATOUS    CONJUNCTIVITIS  235 

Although  the  separation  of  trachoma  into  these  varieties  is  con- 
venient from  the  clinical  standpoint,  such  a  separation  cannot  be  main- 
tained on  histologic  grounds.  Indeed,  Saemisch  maintains  that  the 
terms  "  papillary"  and  "  follicular  trachoma"  should  be  avoided,  as  the 
first  corresponds  with  blennorrhea,  and  the  second  with  follicular  con- 
junctivitis. Certainly  the  term  "follicular  trachoma"  has  given  rise 
to  a  good  deal  of  confusion  in  its  various  interpretations. 

Symptoms. — The  "granulations  or  follicles"  often  appear  without 
antecedent  inflammation,  and  so  insidiously  that  their  real  nature  is  for 
a  time  unknown  to  the  patient.  They  usually  arise  in  the  form  of 
grayish-white,  semitransparent  bodies,  which  vary  in  size  according  to 
their  stage  of  development,  and  which,  from  fancied  resemblances, 
have  been  called  "sago-grain"  or  "vesicular"  granulations.  They 
may  be  disseminated  or  arranged  in  parallel  rows,  and  have  sometimes 
been  likened  to  the  appearance  of  frog's  spawn  (follicular  trachoma). 
The  granulations  are,  for  the  most  part,  confined  to  the  palpebral  con- 
junctiva, and  the  upper  retrotarsal  fold,  which  is  a  favorite  location, 
should  be  well  exposed  during  the  examination.  They  are  also 
found  on  the  bulbar  conjunctiva,  the  caruncle  and  semilunar  folds. 

The  mucous  membrane  is  pale  or  yellowish  red,  unevenly  rough, 
and  contains  the  trachoma  bodies,  or  follicles,  which  have  a  more  or  less 
deep  situation  and  fill  iip  the  tissue.  If  they  have  not  followed  an 
acute  process,  there  are  few  or  no  irritative  manifestations  and  little 
discharge — perhaps  only  sufficient  to  glue  together  the  lids.  As  time 
goes  on  the  closely  packed  masses  compress  the  true  conjunctival  tissue 
and  its  circulation,  and  a  superficial  vascularity  of  the  cornea  may 
appear.  This  stage  may  last  for  months  and  be  subject  to  numerous 
variations. 

In  the  next  stage  vascularity  is  increased,  the  follicles  grow  larger, 
soften,  and  their  contents  are  forced  out  by  the  pressure  of  the  sur- 
rounding infiltrations,  forming,  in  association  with  the  hypertrophied 
conjunctival  papillae,  red  protuberances  (hypertrophied  pseudopapillse) . 
This  period  is  associated  with  strong  irritation  and  mucopurulent  or 
purulent  secretion,  photophobia,  local  pain,  and  corneal  complications. 

During  the  time  of  fatty  degeneration  and  softening,  which  by  some 
authorities  is  deemed  a  process  of  ulceration,  fresh  follicular  (granular) 
eruptions  take  place,  in  turn  to  go  through  the  same  changes  which 
their  forerunners  have  undergone.  The  mucous  membrane  now  has  a 
flesh-red  appearance;  it  is  with  difficulty  that  the  "granulations"  are 
distinguished  from  the  papillae,  and,  indeed,  they  are  united  with  them, 
forming  variouslj^  shaped  diffuse  or  isolated  protuberances.  Sometimes 
resorption  of  the  follicles,  which  can  take  place  at  any  stage,  appears  to 
occur  by  retrogression  without  softening.  Usually  degenerative 
changes  in  the  cells  take  place.  Fusion  and  softening  of  the  closely 
packed  follicles  may  be  followed  by  hyaline  degeneration,  giving  rise 
to  a  gelatinous  appearance,  which  is  sometimes  designated  gelatinous 
trachoma. 

In  the  final' stage  cicatrization  begins,  and  gray- white  scar-lines 


236  DISEASES    OF    THE    COXJIXCTIVA 

appear,  intersecting  the  remains  of  the  old  "granulations."  If 
these  cicatrices  lie  parallel  to  the  ciliary  borders,  they  present,  on  aver- 
sion of  the  lid,  a  typical  appearance^  (Fig.  112). 

By  a  gradual  jiroccss  of  cicatrization  of  the  old  "granulations"  and 
by  the  advent  of  successive  new  crops,  a  chronic  induration  and  diffuse 
scar  tissues  results  {cicatricial  trachoma).  This  being  firmly  attached  to 
the  tarsus,  which  itself  has  undergone  inflammatory  and  lymphoid  infil- 
tration, contracts,  and  the  deformities  of  the  lid  and  its  border,  so  com- 
mon in  this  disease,  result.  The  fibroid  induration  of  the  mucous 
membrane  affects  all  portions,  and  there  may  be  almost  entire  oblitera- 
tion of  the  conjunctival  sulcus,  or  the  membrane  may  undergo  a  species 
of  drying  up,  to  which  the  name  xerosis  has  been  applied.  Individuals 
with  granular  conjunctivitis,  in  the  stage  of  thickening  of  the  mucous 
membrane,  have  an  almost  characteristic  sleepy  look.  j)eering  uncer- 
tainly through  narrowed  palpebral  fissures,  caused  l)y  the  ptosis-like 
droop  of  their  indurated  eyelids. 

In  so-called  acute  granular  conjunctivitis  the  lids  are  swollen,  the 
conjunctiva  reddened,  the  conjunctival  pseudopapilla?  hypertrophied 
and  elevated  bj^  the  underlying  lymphoid  infiltration,  while  i)etween 
them  are  found  the  yellowish,  round  "granulations."  The  dread  of 
light  is  intense,  and  in  forcible  separation  of  the  lids  scalding  tears  gush 
out,  and  later  inucopurulent  discharge  appears.  Still  later,  vasculariza- 
tion and  ulceration  of  the  cornea  may  develop.  Such  manifestations 
are  not  a  special  form  of  trachoma,  but  should  be  regarded  as  a  mix- 
ture of  granular  conjunctivitis  and  catarrh;  acute  exacerbations  of 
chronic  trachoma  are  common  (see  also  page  230). 

Sequelae  and  Complications  of  Trachoma. — The  most  important 
results  of  long-standing  trachoma  are  trichiasis,  distichiasis,  and 
entropion,  conditions  already  described  (see  page  192),  atrophy  and 
shrinking  of  the  conjunctiva  from  cicatricial  changes  (see  page  247). 
cloudiness  and  ulceration  of  the  cornea,  and  pannus. 

Pannus  is  the  development  on  the  cornea  of  a  gelatinous  vascular 
tissue,  which  usually  begins  in  that  portion  of  the  cornea  covered  by 
the  upper  lid  (sometimes  below  or  at  one  side),  but  which,  in  severe 
cases,  may  involve  its  entire  surface.  It  depends  upon  the  formation 
of  new  blood-vessels  between  the  corneal  epithelium  and  Bownum's 
membrane,  associated  with  collect it)ns  of  I'ountl  cells.  It  may  be 
composed  of  only  a  few  vessels  (pannus  tenicis),  or  be  thick,  fleshy 
(panmis  crassus),  and  bulging  in  appearance.  If  soft(>ning  and 
ulceration  occur,  the  true  corneal  tissue  is  invadeil. 

Pannus  is  not  a  simple  traumatic  irritation  tlue  to  the  action  oi  the 
roughened  lid  (although  this  ma}''  be  a  predisposing  factor),  but  is 
a  special  implantation  of  the  trachoma  process  on  the  layers  of  the 
cornea.  Extensive  and  deep  ulceration  may  complicate  pannus, 
which,  in  turn,  may  lead  1(»  the  devel(t|)nient  of  iritis;  or  the  cornea 

'  It  is  ccjiiveniont  to  thus  divide  tlio  disease  into  three  stano.s,  as  lljiohhnann 
has  done,  hut  it  is  not  always  possilili-  in  scp.-u-Mte  sliarply  each  sta^e  by  syin|)toius 
or  ttppearaiiees  peculiar  to  itself. 


I 


TRACHOMATOUS    CONJUNCTIVITIS 


237 


may  become  entirely  opaque;  or,  finallj^,  the  ulceration  may  be  fol- 
lowed by  perforation  of  this  membrane  and  staphylomatous  bulging. 
The  ulcers  may  begin  at  the  border  of  the  pannus  (a  favorite  situation) 
or  within  the  area  of  the  pannus,  or  in  some  portion  of  the  cornea  not 
otherwise  affected. 

In  some  of  the  subjects  of  trachoma  dacryocystitis  is  present  and 
trachomatous  changes  may  be  detected  in  the  walls  of  the  sac  and  even 
in  the  nose.     The  inner  end  of  ... 

the    canaliculus    is    frequently     i  \ 

occluded    in    trachomatous     _ 
patients.  ! 

Diagnosis. — An  examination 
of  fresh  material  should  reveal 
the  Prowazek-Greeff  granules, 
but,  as  has  already  been  pointed 
out,  the  presence  of  these  bodies, 
while  highly  significant,  is  not 
sufficient  to  establish  a  diag- 
nosis; i.  e.,  their  absence  does 
not  exclude  trachoma.  The 
disease  is  made  evident  by  di- 
rect inspection  of  the  everted 
lids  unless  the  associated  swell- 
ing of  the  papillae  is  so  great 
as  to  obscure  the  "granula- 
tions," especially  in  the  forms 
of  papillarj^  trachoma.  Hyper- 
trophied  conjunctival  papilUe, 
chronic  blennorrhea,  and  sur- 
face granulations  must  not  be 
mistaken  for  trachoma;  the 
thickening  and  induration  of 
the  tarsus  is  a  distinguishing 
feature  in  granular  conjuncti- 
vitis. The  clinical  distinctions  existing  between  trachoma  and 
follicular  conjunctivitis  have  been  pointed  out  (see  page  229).  The 
distinctions  between  vernal  conjunctivitis,  Parinaud's  conjunctivitis, 
tuberculosis  of  the  conjunctiva  are  elsewhere  described.  In  early 
stages  of  trachoma  loupe-investigation  of  the  upper  portion  of  the 
cornea  will  not  infrequently  detect  a  delicate  ingrowth  of  vessels 
(earlj^  stage  of  pannus)  not  discoverable  with  the  naked  eye  (Stieren  and 
Van  Kirk).  Great  care  should  be  exercised  in  the  inspection  of  im- 
migrants, and  those  undoubtedly  trachomatous  should  be  deported. 
All  suspected  persons,  and  all  those  in  whom  the  diagnosis  is  uncertain, 
should  be  isolated  and  detained  until  the  exact  nature  of  their  con- 
junctival trouble  is  ascertained. 

Prognosis. — In    the    best    circumstances,    trachoma,    when    well 
established,  is  a  tedious  disease,  and  greatly  endangers  the  vision  of  the 


Fig.    113. — Typical  pannus  with  line  of  de- 
markation  (Medical  War  Manual  No.  3). 


238  "diseases  of  the  conjunctiva 

patient.  Relapses  are  frequent,  and  at  any  time  the  disorder  is  likel}'  to 
assume  an  intense  inflammatory  action.  Its  communicable  character 
renders  the  affection  especially  dangerous  in  schools  and  in  any  insti- 
tution where  large  numbers  of  inmates  are  gathered  together.  The 
discharge,  even  when  present  in  slight  degree,  is  readily  conveyed  from 
one  subject  to  another  by  the  careless  use  of  towels  and  common  uten- 
sils. Great  caution  is  necessary  in  such  circumstances  to  prevent  a 
disastrous  epidemic.  Trachoma,  if  properly  managed,  is  curable 
and  improvement  in  prognosis  in  recent  years  under  the  influence  of 
well  considered  operative  procedures  and  medicamental  appUcations, 
has  been  evident. 

Treatment. — The  treatment  of  chronic  trachoma  includes  the 
application  of  caustics,  astringents,  antiseptics,  and  certain  so-called 
specific  remedies,  operative  procedures,  and  general  medication. 

Local  applications  of  astringent  and  caustic  preparations  are  used 
to  cause  absorption  of  the  "granulations,"  but  these  should  not  be  of 
such  strength  as  to  produce  cicatricial  changes  more  harmful  than  the 
original  malady. 

A  variety  of  substances  has  been  emplo^-ed;  indeed,  it  is  safe  to 
assert  that  there  is  scarcely  an  antiseptic  or  caustic  agent  the  use  of 
which  is  permissible  in  ocular  disorders  that  has  not  been  tried  in 
the  effort  to  alleviate  the  symptoms  of  this  disease.  If  granular  con- 
junctivitis is  associated  with  much  discharge  in  the  sense  of  mucopuru- 
lent secretion,  the  ordinary  antiseptic  and  slight]}'  astringent  lotions 
are  useful,  and  should  be  freely  employed  to  irrigate  the  conjunctival 
culdesac.  Those  which  serve  the  best  purpose  are  saturated  solutions 
of  boric  acid,  bichlorid  of  mercury  (1  :5000  or  1  :  10,000),  and  cyanid 
of  mercury  (1  :  2000)  and  mercurophen  (1:8000).  Sulphate  of  zinc 
(0.5-1  per  cent.)  has  been  much  employed  and  was  found  of  dis- 
tinct advantage  in  the  routine  treatment  of  trachoma  during  the  late 
war. 

Formerly,  during  the  stage  of  conspicuous  lymphoid  infiltration  and 
decided  follicular  eruption,  without  the  presence  of  much  discharge,  the 
direct  application  to  the  everted  lids  of  strong  solutions  of  bichlorid  of 
mercury  (1  :  300  or  1  :500)  were  much  employed,  and  at  one  time  the 
author  was  ijnpressed  with  their  value,  but  in  recc^it  years  has  practi- 
cally discontinued  them. 

In  the  stage  of  softening  of  the  granulations  and  swelling  of  the 
conjunctival  pseudopapilla),  associated  with  mucopuniUMit  and  puru- 
lent discharge,  in  adtlition  to  fhishings  with  the  antiseptic  solutions 
already  incut  ioiied,  nitrate  of  silver  is  of  value,  employed  in  the  manner 
already'  described  (see  page  214).  (lenerally  it  is  not  necessary  to  use 
a  solution  stronger  than  2  per  cent.  Instead  «»r  nitrate  of  silver, 
argyrol  and  protargol  in  the  usual  strengths  may  be  employed.  In 
this  stage  solutions  of  permanganate  of  potassium  (1  :.'i(IO()  and  1  : 
5000)  have  been  advocated,  while  stronger  sohitions  (1:1000)  liave 
becm  applied  dirc'ctly  to  the  everted  lid. 

At  one  time  sulphate  of  copper  was  almost  uiiiveisall\  employed  in 


TRACHOMATOUS    CONJUNCTIVITIS  239 

the  treatment  of  trachoma,  and  the  author  is  convinced  that  it  still 
occupies  a  most  useful  place  in  the  management  of  this  affection.  The 
value  of  sulphate  of  copper  depends  upon  its  power  to  excite  phagocytic 
activity.  Where  the  eruption  of  new  granulations  is  associated  with 
beginning  cicatricial  metamorphoses  of  old  crops  and  their  surrounding 
tissue,  this  remedy  is  of  advantage.  The  crystal  of  sulphate  of  copper 
should  be  smooth  and  carefully  applied  to  all  portions  of  the  a'^.ected 
areas,  especially  to  the  retrotarsal  folds,  and  the  treatment  followed 
by  washing  the  surface  with  cold  water.  It  is  a  painful  remedy,  and 
in  sensitive  patients  there  is  no  objection  to  holocainizing  the  eye.  In 
order  to  render  sulphate  of  copper  painless,  it  has  been  suggested  to 
fuse  it  into  a  crayon  composed  of  this  drug,  orthoform,  holocain,  and 
gum  tragacanth.  Sulphate  of  copper,  dissolved  in  glycerin  (5  per  cent, 
solution)  is  a  most  useful  application. 

In  place  of  sulphate  of  copper,  copper  citrate  (cuprocitrol),  origin- 
ally recommended  by  F.  R.  von  Arlt,  has  found  favor  with  some 
surgeons.  It  may  be  employed  in  a  5  or  10  per  cent,  ointment,  which 
is  introduced  well  in  the  conjunctival  sac,  and  gentle  but  thorough 
massage  used  immediately  afterward. 

During  the  later  stages  of  trachoma,  in  order  to  hasten  the  absorp- 
tion of  remaining  granulations  and  perhaps  to  prevent  the  tendency  to 
xerosis,  boroglycerid  (30-50  per  cent.)  is  a  useful  remedy,  applied  in  the 
usual  manner  with  a  cotton  mop.  In  mild  cases,  or  after  an  impression 
has  been  made  with  stronger  caustics,  a  favorite  astringent  is  tannin 
and  glycerin,  30  to  60  grains  to  1  ounce  (1.95-3.9  gm.  to  30  c.c),  or  the 
everted  lids  may  be  touched  with  an  alum  crj^stal.  Among  the  many 
additional  remedies  which  have  been  tried  in  this  affection  the  following 
may  be  mentioned :  Liquid  carbolic  acid,  liquor  potassa,  betanaphthol, 
hydrastin,  iodoform,  or  aristol  (in  powder  or  salve),  an  ointment  of  the 
yellow  oxid  of  mercury,  calomel,  iodid  of  silver,  ichthargan  (2  to  3  per 
cent.),  itrol  in  powder,  ichthyol,  and  cyanid  of  mercury  (1:500),  which 
is  energetically  rubbed  by  means  of  a  tampon  of  cotton  wool  over  the 
granular  surface. 

Trachoma  is  liable  at  any  time  to  develop  acute  symptoms:  in- 
creased discharge;  exacerbation  of  pannus,  with  clouding  and  ulceration 
of  the  cornea;  hyperemia  of  the  iris,  and  acute  pain  in  the  brow  and 
temple.  Usually  severe  local  applications  must  be  discontinued,  and 
the  treatment  instituted  which  is  apphcable  to  acute  conjunctivitis, 
and  which  need  not  be  here  repeated.  Hot  compresses  are  often  agree- 
able, and  the  pupils  should  be  dilated  with  a  solution  of  atropin  or 
scopolamin.  In  this  stage  and,  indeed,  in  other  stages,  especially  if 
pannus  is  present,  it  would  seem  that  dionin  is  of  some  value. 

The  x-ray  treatment  of  trachoma  has  occupied  a  very  large  share  of 
attention  within  the  last  few  years,  and  has  been  recommended  by 
Mayou,  Stephenson,  Walsh,  and  other  surgeons. 

The  author's  experience  with  this  method  of  treatment  is  too  limited 
to  render  an  expression  of  opinion  from  him  of  value.  In  the  few  cases 
in  which  he  has  used  it  and  seen  it  employed  the  results  were  indifferent, 


240  DISEASES    OF   THE    CONJUNCTIVA 

certainly  not  any  better  than  those  obtained  by  ordinary  therapeutic 
agents  or  operative  procethire. 

Radium  has  also  been  used  in  the  treatment  of  trachoma,  but 
Charles  H.  ^Nlay,  who  has  studied  the  action  of  this  substance  in  this 
respect,  concludes  that  the  results  obtained  are  not  so  favorable  as 
those  secured  with  sulphate  of  copper.  Carbon  dioxid  snow  has  also 
been  employed;  applications  are  made  for  a  few  seconds  once  a  week 
at  first,  later  the  time  may  l)e  increased  to  twentj'  seconds.  It  is 
commended  by  Treacher  Collins  and  T3'rrell. 

Stephenson  and  Walsh  also  recommend  the  application  of  the 
high-frequency  current  through  a  vulcanite  electrode  applit^l  to  the 
upper  lid  in  the  treatment  of  severe  trachoma. 

Operative  Procedures. — These  include  the  various  methods  for  re- 
moving the  granulations:  Scarification  of  the  conjunctiva;  abscission 
of  the  granulation;  excision  of  the  retrotarsal  fold  or  of  a  strip  of  the 
infiltrated  fornix;  removal  of  a  part  of  the  tarsal  conjunctiva  at  the 
same  time  that  the  strip  of  infiltrated  fornix  is  excised  (the  so-called 
combined  excision);  extirpation  of  the  tarsus  (Kuhnt's  extirpation) 
and  squeezing  or  rolling  out  the  trachoma  follicles  with  suitable  instru- 
ments, especially  with  Noyes',  Knapp's,  or  Kuhnt's  forceps.  Removal 
of  the  granulations  by  means  of  a  curet  or  stiff  brush,  and  then  rubbing 
into  them  strong  solutions  of  bichlorid  of  mercury  or  cyanid  of  mercury 
(grattage,  brassage),  are  measures  that  have  been  much  employed. 
Grattage  is  performed  by  D.  H.  Coover  with  strips  of  sterilized  sand- 
paper. The  methods  of  applying  the  various  operative  procedures  are 
described  on  page  686. 

Of  the  methods  just  enumerated,  expression  of  the  follicles  with 
suitable  forceps,  particularly  in  the  so-called  follicular  forms  of  trach- 
oma, is  the  most  satisfactory,  although  both  simple  and  combined 
excision  of  the  infiltratcnl  fornix  sometimes  yields  exce(>dingly  satis- 
factory results.  Some  surgeons,  notably  Mr.  ( ieorge  Lindsay  Johnson, 
recommend  electrolysis  in  the  treatment  of  trachoma. 

Treatment  of  Trachoma  with  Pannus. — If  the  pannus  is  limited  in 
degree,  it  requires  no  special  treatment,  as  it  will  disappear  witii  the 
absorption  of  the  granulations;  but  if  it  is  extensive,  and  especially  if 
as.sociated  with  ulceration,  special  treatment  should  be  directed  toward 
its  cure.  This  includes  the  local  remedies  which  are  appropriate  for  a 
vascular  keratitis,  namely,  an  antiseptic  lotion,  the  various  mydriatics, 
and  occasionally  dionin. 

Inveterate  pannus,  without  ulceration  of  the  cornea,  at  one  time 
was  treated  l)y  tlie  production  of  a  violent  conjunctivitis,  character- 
iz<'d  by  the  formation  of  a  somewhat  clinging  false  membrane,  with  a  3 
per  (Till,  infusion  oi  jrquirHy,  painted  upon  the  everted  lids.  This 
method  was  inti'oduced  by  de  Wecker  to  substitute  the  old-fiishioned 
inocuhition  of  the  conjunctiva  with  bleiuiorrheic  pus. 

Since  the  introduction  into  ophthalmic  practice  of  jequiritol  and 
jequiritol  serum  by  lioemer,  these  substances  iiave  been  mucii  employed 
in  the  treatment  of  trachoma.     .h'<|uiiiloI  is  an  extract  made  from  the 


-i 


parinaud's  conjunctivitis  241 

seed  of  the  abrus  precatorius.  It  is  used  in  a  sterile  solution  mixed  with 
50  per  cent,  glycerin,  so  that  an  exact  dose  can  be  given  without  evil 
effects,  which  was  not  possible  with  abrin  or  the  old  infusion.  Ac- 
cording to  Hoor,  jequiritol  is  indicated  in  old  trachomatous  pannus  with 
cicatrized  and  degenerated  conjunctiva.  It  is  contraindicated  in 
purulent  processes  of  the  cornea,  in  recent  opacities,  and  in  fresh 
trachomatous  pannus.  In  spite  of  all  care  certain  complications  may 
arise — for  example,  edema  of  the  lids,  pain,  facial  eczema,  and  suppura- 
tion of  the  lacrimal  sac.  Evidently  jequiritol  is  not  without  danger, 
and  should  be  restricted  if  used  at  all  to  the  cases  already  described. 

The  operation  of  peritomy,  which  consists  of  an  excision  of  a  ring  of 
conjunctival  tissue  surrounding  the  cornea,  has  been  much  practised 
for  the  relief  of  severe  pannus.  Another  method  is  to  scrape  away  the 
opaque  and  vascular  areas  in  the  cornea  with  a  small  knife  (Gruening). 
If  the  palpebral  fissure  becomes  contracted  by  cicatricial  changes,  or  if 
during  inflammatory  periods  in  trachoma  the  lids  dangerously  com- 
press the  cornea,  the  operation  of  canthoplasty  affords  relief. 

General  Medication. — It  is  a  mistake  to  depend  solely  upon  local 
measures  for  the  relief  of  granular  conjunctivitis,  for,  although  the  dis- 
ease has  no  proved  constitutional  origin,  its  subjects  give  frequent  evi- 
dence of  malnutrition,  and  are  sometimes  affected  with  tuberculosis. 
Hygienic  surroundings,  iron,  cod-liver  oil,  hypophosphite  of  lime, 
arsenic,  and,  in  short,  a  general  tonic  regimen  are  indicated.  Suitable 
attention  to  the  alimentary  tract  is  important.  The  internal  adminis- 
tration of  iodid  of  potassium  has  been  advised  (Brown  Pusey). 

Parinaud's  Conjunctivitis  (Infections  Conjunctivitis;  Septic  Con- 
junctivitis; Lymphoma  of  the  Conjunctiva  [Goldzieher]  Leptothricosis 
conjunctiva  [Verhoeff]). — This  rather  rare  form  of  conjunctival  affection 
was  first  accurately  described  bj^  Parinaud  in  1889,  and  has  in  recent 
times  been  the  subject  of  verj^  extended  researches,  particularly  by 
Chaillous  in  France,  and  Gifford,  Verhoeff  and  G.  S.  Derby  in  this 
country.  According  to  the  last-named  authors,  the  disease  has  been 
observed  only  in  the  temperate  zone,  and  occurs  a  little  more  frequently 
in  the  autumn  than  at  other  seasons.  The  sexes  are  about  equally 
affected,  and  all  ages  seem  liable  to  it,  the  youngest  patient  recorded 
being  one  and  a  half  years  of  age  and  the  oldest  fifty-nine.  More  com- 
monly it  is  a  unilateral  than  a  bilateral  disease;  indeed,  in  only  a  very 
few  instances  have  both  eyes  been  affected. 

The  chief  symptoms  are  the  following:  Swelling  of  the  lid,  usually 
most  marked  in  the  upper  lid,  hj'peremia  and  edema  of  the  bulbar  con- 
junctiva, and  a  moderate  mucopurulent  discharge.  The  characteristic 
conjunctival  lesions  consist  of  large,  reddish,  semitransparent  poly- 
poid vegetations,  small  yellowish  granules,  erosions,  and  superficial 
ulcers.  Sometimes  the  conjunctival  growths  are  pedunculated.  Very 
rarely  corneal  changes  in  the  form  of  keratitis  have  been  described. 
Glandular  involvement  usually  takes  place  simultaneously  with  or  very 
soon  after  the  development  of  the  ocular  disease.  In  a  few  instances  it 
has  preceded  them.     Most  often  the  preauricular  glands  are  affected; 

16 


242  DISEASES    OF    THE    rOXJUXrTIVA 

more  rarely  the  retroinaxillary,  the  parotid,  the  submaxillary,  and  the 
cervical.  Occasionally  acute  tonsillitis  has  been  noted.  The  disease 
may  last  from  one  to  five  months. 

So  far,  investigations  have  failed  to  isolate  any  of  the  known  micro- 
organisms as  a  causative  agent  of  this  disease,  although  McCrae  found 
in  one  case  a  bacillus  which  resembled  the  Klebs-Loffler  bacillus,  which 
he  regarded  as  the  probable  excitant  of  the  ocular  inflammation. 
Sinclair  and  Shcnnan  isolated  two  varieties  of  white  staphylococci 
from  the  necrotic  areas  in  one  case.  Parinaud  beheved  that  the  disease 
was  of  animal  origin,  and  Hoor  maintains  that  in  the  majority  of  cases 
there  is  a  history  of  an  opportunity  of  animal  contagion ;  ijut  VerhoeflF 
and  Derby  regard  this  theory,  at  present  at  least,  as  unsubstantiated. 
Herrenschwand  has  investigated  a  form  of  conjunctivitis  similar  to 
Parinaud 's  attributed  to  the  bacillus  pseudo-tuberculosis  rodentium,  aLt 
observation  which  he  thinks  lends  support  to  the  theory  that  Parinaud 's 
conjunctivitis  is  of  animal  origin.  Recently  VerhoefT  has  found  in  the 
lesions  of  this  a  ection  a  filamentous  organism  classified  as  a  leptothrix, 
which  he  regards  as  the  cause  of  the  disease.  There  may  be  difficulty 
in  distinguishing  the  disease  from  tuberculosis  of  the  conjunctiva, 
(which  is  said  to  be  associated  with  the  lesions  in  some  cases)  and  to 
reach  a  definite  diagnosis  it  may  be  necessary  to  inoculate  the  anterior 
chamber  of  a  rabbit's  eye  with  a  fragment  of  the  suspected  tissue. 
Microscopic  examination  of  the  excised  tissue  reveals  cellular  infiltra- 
tion, consisting  of  lymphoid  and  phagocytic  cells  and  marked  cellular 
necrosis.  According  to  Verhoeff  the  essential  lesion  is  a  focal  area 
3  mm.  in  diameter  or  larger,  backed  with  cndolthelial  phagocytes 
loaded  with  broken  down  chromatin  granules,  which  is  situated  just 
beneath    the    epithelium. 

The  treatment  recommended  includes  the  ordinary  antiseptic  col- 
lyria,  nitrate  of  silver,  or  the  newer  silver  salts,  applications  of  sulphate 
of  copper,  and  excision  of  the  granulations.  The  inj(>cti()n  of  antidiph- 
theritic  serum  has  been  tried,  anil  Sinclair  and  Shennan  have 
instituted  vaccine  treatment,  but  the  patient  did  not  remain  under 
observation  for  a  sufficient  time  to  demonstrate  the  value  of  the  method. 

Sporotrichosis  of  the  conjLl^cti^a  has  l)een  reported  by  Morax. 
Cruchandcau,  (iilTord,  A.  Knapp  and  others.  ThicUciiing  of  the  liil. 
nodular  swelling  of  the  conjunctiva,  superficial  yellowish  ulcers,  ami 
adenopathy  were  present.     (See  also  page  178.) 

Chronic  conjunctivitis  (Chronic  ophthalmia),  the  result  of  an 
a(;ut('  hlcriiMti  ihca,  has  been  referred  to  on  j)age  211*. 

As  an  independent,  di.sortler,  and  assuming  more  the  type  of  a  hy- 
p(!remia,  it  is  a  conunon  di.sease  in  elderlj'  persons.  IMiere  are  hy- 
peremia, thickening  of  the  i)apillary  layer  of  the  tarsal  conjunctiva, 
.swelling  (^f  the  caruncle,  soreness  of  the  edges  of  the  lids,  and  slight 
mucopurulent  discharge.  ()ften  the  bulbar  eonjuni'tiva  is  not;il)ly 
injected.  Chronic  conjunctivitis  due  to  hypersecretiim  of  the  Mei- 
bomian glands  [citnju/uiiritis  imibuniiaiia)  and  to  "insulliciencx'  of  the 


LACRIMAL    CONJUNCTIVITIS  243 

eyelids,"  so  that  they  close  only  with  e!:ort  and  remain  open  during 
sleep,  is  described  by  Elschnig.  The  latter  may  result  in  a  form  of 
xerosis  of  the  conjunctiva  (tyloma  conjunctivce,  Saemisch).  A  chronic 
conjunctivitis  of  moderate  severity  with  only  slight  injection  and  traces 
of  abnormal  secretion  in  the  commissural  angles  has  been  called  con- 
junctivitis  sicca,  and  is  especially  aggravating  on  awakening.  It  is  to 
this  aTection  that  the  so-called  "morning  ptosis"  is  usually  due,  the 
patient  being  unable  to  open  the  eyes  except  with  the  help  of  the  fingers, 
which  elevate  the  lid.  The  relation  of  the  diplobacillus  to  chronic  and 
subacute  conjunctivitis  has  been  described  (see  page  205;  see  also 
Hyperemia  of  the  Conjunctiva,  page  199).  In  association  with  chronic 
conjunctivitis  and  chronic  ciliary  blepharitis  delicate  flame-shaped 
marginal  keratitis  may  arise,  the  lesions  having  their  bases  at  the  lim- 
bus  and  their  apices  advanced  about  one-third  wav  across  the  cornea 
(W.  T.  Holmes  Spicer). 

Treatment. — Cleanliness,  with  antiseptic  lotions,  the  application 
of  "lapis  divinus,"  an  alum  crystal,  or  glycerol  of  tannin,  gr,  x  tofgj 
(0.65  gm.  to  30  c.c),  are  useful  local  measures.  Aqueous  sokitions  of 
suprarenal  extract  (8  per  cent.)  or  adrenalin  chlorid  (1  :  10,000)  will 
temporarily  dissipate  the  congestion,  but  they  are  not  curative  in  their 
action.  The  puncta  lachrymalia  should  be  examined,  and  if  they  are 
closed,  they  should  be  dilated  and  the  lacrimal  passages  irrigated  with 
an  Anel  syringe,  and  the  nasal  chambers  should  be  carefully  treated. 
Refractive  error,  which  may  keep  up  congestion,  requires  correction. 
For  conjunctivitis  meibomiana  emptying  of  the  Meibomian  glands  is 
recommended  (Elschnig,  Fridenberg).  Boric  acid  in  lanolin  (2  per 
cent.)  is  useful  if  the  conjunctival  surface  is  too  dry.  If  the  Morax- 
Axenfeld  bacillus  is  present,  solutions  of  zinc  sulphate  or  chlorid  should 
be  used  (see  page  207). 

Egyptian  and  military  conjunctivitis  are  terms  which  have  at 
different  times  been  loosely  used  to  describe  all  forms  of  conjunctival 
inflammations  occurring  in  crowded  barracks  and  similar  institutions, 
which  assumed  an  epidemic  tendency,  pursued  a  more  or  less  chronic 
course,  and  hence  included  varieties  of  acute  and  chronic  blennorrhea 
and  mucopurulent  conjunctivitis,  in  addition  to  those  cases  which 
possessed  as  a  fundamental  diagnostic  symptom  "  granulations"  of  the 
conjunctiva,  and  which  eventuated  in  the  formation  of  cicatrices. 

Lacrimal  conjunctivitis  is  really  a  form  of  chronic  conjunctivitis 
depending  upon  obstruction  of  the  lacrimal  passages  and  the  frequently 
associated  blepharitis,  and  in  the  discharge  of  which  streptococci  are 
found.  The  eyelids  are  inflamed  upon  their  borders,  the  cilia  gathered 
in  little  tufts  by  the  formation  of  small  pustules  at  their  bases,  the 
conjunctiva  is  injected  and  tear-soaked,  and  there  is  a  somewhat  gummy 
discharge.  This  form  of  conjunctivitis  may  be  complicated,,  according 
to  Parinaud,  with  hypopyon  and  iridocyclitis. 

The  treatment  requires  that  the  lacrimal  passages  shall  be  rendered 
patulous,  in  addition  to  the  ordinary  remedies  suitable  for  chronic  con- 
junctivitis and  ulcerated  blepharitis. 


244  DISEASES    OF    THE    CONJUNCTIVA 

Lithiasis  conjunctivae  is  a  troublesome  condition  caused  by  a  cal- 
careous dpficncration  of  inspissated  secretion  in  the  acini  of  meibomian 
glands.  It  is  more  conmionly  seen  in  elderly  people  than  in  young  sub- 
jects, especially  if  the^-  are  gouty.  On  everting  the  lids,  numerous 
small,  yellowish-white  concretions  will  be  seen  distinctly  gritty  to  the 
touch.  These  act  like  so  many  foreign  bodies  and  produce  consider- 
able irritation  and  pain. 

Each  concretion  should  be  removed  with  a  fin(^  needle,  the  con- 
junctiva having  first  been  rendered  insensitive  with  cocain. 

Toxic  conjunctivitis  is  a  name  suited  to  those  forms  of  conjunc- 
tival inflammation  caused  by  certain  chemicals,  by  insects,  and  by  the 
prolonged  use  of  the  mj'driatics  (notably  atropinj  anil  the  miotics. 

Atropin  conjunctivitis  occurs  at  all  ages,  but  is  commonest  in  old 
persons.  Sometimes  it  will  appear  after  only  a  few  tlrops  of  the  solu- 
tion have  been  used,  but  usuallj'  not  until  the  drug  has  been  employed 
for  a  long  time.  It  has  been  attributed  to  impurities  in  the  drug,  to  the 
existence  of  free  acid,  to  the  presence  of  a  fungoid  growth,  and  to 
idiosyncrasy.  In  a  number  of  instances  arthritic  history  has  been 
obtained  (Collins).  The  disease  usually  appears  in  the  form  of  follicu- 
lar granulations,  sometimes  associated  with  much  swelling  of  the  lid 
and  eczema  of  the  surrounding  tissue.     (See  also  page  228). 

Eserin,  hyoscj'amin,  duboisin,  and  homatropin  less  commonly 
cause  this  affection,  and  the  same  disorder  has  been  reported  as  the 
result  of  the  prolonged  use  of  cocain. 

Conjunctivitis  occurs  among  those  who  work  in  anilin  dyes,  and 
from  chryosphanic  acid,  when  this  has  been  usetl  as  an  ointment  in  skin 
affections,  and  may  be  caused  by  artificial  fertilizers.  Chryftarobin 
conjunctivitis  (photophobia,  lacrimation  and  blepharospasm)  may, 
according  to  Igersh(;imer,  be  associated  with  gray  deposits  in  the  cornea, 
resembling  superficial  punctate  keratitis.  Poilophyllin  coming  in  con- 
tact with  the  eye  may  produce  intense  congestion,  edema  of  the  lids, 
and  infiltration  of  the  cornea  (C.  Chiari). 

Conjunctivitis  caused  by  caustics,  acids,  and  other  strong  irritants 
is  elsewhere  considered.  Workers  with  .r-rays  are  subject  to  a  sm-tMc 
and  at  times  iiitractal)le  form  of  conjunctivitis  (see  page  ')C)0).  Con- 
junctivitis may  follow  tlie  stings  of  flies  and  other  insects,  and  has  been 
described  as  due  to  tlu;  presence  of  larvic  in  the  conjunctival  sac  (hirrnl 
conjunctivitia).  Parasitic  conjunctivitis  due  to  one  of  the  groups  of 
the  higher  fungi  has  been  reported  by  A.  J.  Smith,  C.  M.  Ilosmer,  J.  T. 
Carpenter,  .li.,  and  W.  C.  Po.sey.  Violent  conjunctivitis  may  be 
caused  by  the  venom  of  certain  serjx'nts,  by  eel-blood,  and  contact 
with  ascarides.  Some  persons  ([uickly  acijuire  a  sharp  conjunctivitis 
if  they  come  near  horses,  for  example,  in  driving,  or  if  they  stroke  tl\<' 
fur  of  a  cat  or  work  among  certain  flowers,  notal)ly  the  |)rinn-osr,  or  if 
plant  hairs  gain  entiance  to  the  conjunctival  sac. 

Traumatic  conjunctivitis  includes  among  its  etiologic  factors 
some  of  the  inilating  substances  described  in  coiuiectio!i  with  toxic 
conjunctivitis,      it    ;il.>^o  arises  freijuently   :is   thi-   resuh    of   wounds  of 


* 


POISONOUS   GAS   CONJUNCTIVITIS  245 

the  conjunctival  membrane,  of  the  entrance  of  foreign  bodies  and  of 
contact  with  dust  laden  atmosphere. 

Provoked  conjunctivitis  is  a  term  applied  to  various  forms  of  con- 
junctival inflammation  artificially  induced  by  soldiers  or  recruits  desiring 
to  escape  military  service.  The  late  war  furnished  many  examples 
of  these  conditions.  The  conjunctival  lesions  were  called  into  exist- 
ence by  the  introduction  of  irritating  substances,  for  example  iodid  of 
mercury,  sulphate  of  copper,  tobacco,  powdered  ipecacuanha  and  oil 
of  cloves.  Bacteria  were  rarely  present  in  the  secretion  which  contained 
quantities  of  epithelial  cells.  The  lower  conjunctival  sac  was  chiefly 
and  sometimes  solely  affected. 

The  treatment  in  general  demands  the  removal  of  the  cause,  and  in 
atropin  conjunctivitis  applications  of  tannin  and  glycerin  and  of  an 
alum  crystal  are  useful.  In  some  instances  the  author  has  found  a  1 
per  cent,  solution  of  creolin  of  service.  A  bland  ointment  for  the 
irritated  cutaneous  surface  and  the  ordinary  antiseptic  lotions  are 
indicated.  Boric  acid  lotion,  physiologic  salt  solution  to  which  may 
be  added  holocain  (1  per  cent.),  after  the  cause  has  been  eliminated, 
are  useful  in  the  treatment  of  traumatic  conjunctivitis. 

Poisonous  Gas  Conjunctivitis. — Exposure  to  various  types  of 
poisonous  gases  during  the  late  war  brought  about  the  following  ocular 
conditions : 

Lacrimatory  gas  caused  burning  pain,  profuse  lacrimation, 
chemosis,  swelling  of  the  lid  borders  and  erythema  of  lid  skin.  Occa- 
sionally a  fine  exfoliation  of  the  epithelium  of  the  cornea  at  its  periphery 
was  evident,  but  these  lesions  did  not  extend  and  mild  cases  quickly 
recovered. 

Phosgene  gas  was  not  conspicuous  in  producing  ocular  disorders, 
but  conjunctivitis  of  various  types  was  observed,  occasionally  of  a 
mucopurulent  type. 

The  lesions  of  mustard  gas  (dichlorethyl  sulphide)  resembled  those 
of  a  chemical  burn,  and  were  slight,  moderate  or  severe  in  their  mani- 
festations. Even  in  the  mild  cases  there  were  lacrimation,  spasmodic 
closing  of  the  lid  and  erj^thema  of  their  surfaces. 

In  severe  cases  the  lids  were  pressed  tightly  together,  were  greatly 
reddened  and  often  covered  by  bullae.  The  conjunctiva,  always 
intensely  injected,  became  chemotic,  especially  its  upper  and  lower 
folds,  and  not  infrequently  an  area  of  solid  white  edema  formed  in 
the  palpebral  fissure,  suggesting  somewhat  the  appearance  produced 
by  a  nitrate  of  silver  burn. 

In  mild  types  of  the  affection,  the  corneal  epithelium  was  roughened 
and  slightly  eroded  and  it  stained  with  fluorescin;  in  more  severe 
types  grayish  areas  were  noticeable  in  the  roughened  cornea  (orange 
skin  cornea),  and  in  very  severe  types  the  cornea  was  traversed  by  a 
white  band  in  the  area  of  the  palpebral  fissure.  Secondary  infection 
of  the  cornea  was  common,  especially  if  the  eye  had  unfortunately 
been  bandaged;  conjunctivitis  developed,  and  sometimes  severe 
ulceration,  keratomalacia,  and  even  panophthalmitis. 


246  DISEASES    OF    THE    CON.I  INCTIVA 

Tlic  original  conjunctival  conjicstion  often  was  associated  with  an 
injection  of  the  ciHary  type;  sHght  iritis  has  been  described  (TeuUdres), 
and  even  edema  of  the  ojitic  nerve,  optic  nerve  atroi)hy  and  neuroretin- 
itis.  It  is  doubtful,  however,  if  fundus  lesions  were  ever  directly  due 
to  mustard-gas  poisoning. 

The  mild  or  benign  cases  recovered  usually  within  two  weeks; 
in  moderately  severe  cases,  which  formed  the  greatest  number,  the 
duration  of  the  affection  was  about  six  weeks;  the  white  edema  dis- 
appeared slowly,  being  replacetl  with  a  red  area,  and  often  several 
months  elapsed  before  the  soldiers  thus  a  ected  could  return  to  duty; 
sometimes  the  lesions,  after  subsidence  of  the  white  edema,  resembled 
episcleritis  (Lister). 

Considering  the  severity  of  the  l)urn,  it  is  not  a  little  remarkable 
that  comparatively  few  permanent  visual  disabilities  were  noted,  and 
onl}'  comparatively  rarely  total  loss  of  the  eye,  or  eyes  (keratomalacia, 
panophthalmitis).  In  several  soldiers  observed  by,  and  under  the  care 
of,  the  author  the  ultimate  results  were  deeply  hazed,  moderately 
vascularized  corneas,  the  epithelium  and  deeper  structures  being 
involved  and  vision  reduced  to  hand  movements;  in  one  case  both 
corneas  were  staphylomatous.  In  some  patients,  although  the  corneas 
were  una  ected,  the  bulbar  as  well  as  the  palpebral  conjunctivas 
remained  for  long  periods  of  time  injected;  exacerbations  were  common, 
and  there  was  continuous  dread  of  light. 

Treatment. — The  most  satisfactory  coUyrium  was  as  a  1  per  cent, 
solution  of  bicarbonate  of  soda;  later  boric  acid  lotion  was  useful,  and 
liquid  albolene  was  of  advantage,  but  vegetable  oils,  for  example, 
castor  oil,  was  not  satisfactory.  In  the  presence  of  ciliary  congestion 
and  contracted  pupil  atropin  mydriasis  was  necessary  and  secondary 
conjunctivitis  was  advantageously  treated  with  argyrol.  The  manage- 
ment of  corneal  ulcers  did  not  differ  from  that  of  civilian  practice. 
Bandaging  the  eyes  was  detrimental  and  was  often  the  cause  of  second- 
ary infections.  Eye  shades  or  dark  glasses  were  required,  but  it  was 
important  not  to  keep  the  patients  any  longer  than  absolutely  neces- 
sary in  the  hospital  in  order  to  check  the  tendency  to  neurasthenia. 

Much  work  in  experimental  mustard  gas  conjunctivitis  has  l)een 
done,  and  Wart  bin  iccommonds  a  one-half  of  one  \)vr  I'ent.  solution 
of  dichloramin-T  in  chlorosone  as  a  lotion.  The  j)athologic  exami- 
nation of  gassed  eyes  shows  changes  in  the  corneal  epithelium,  sub- 
stantia propria,  and  in  the  conjunctiva.  The  whole  suliject  «^f  the 
ocular  lesions  produced  by  poisonous  ga.ses  has  been  jiarticularly  well 
studied  in  this  country  ti\-  Di'.  ( Icorge  S.  Derby. 

Conjunctivitis  Nodosa  {Ophthalmia  Xoda.^a;  Pseudotuberculosis  of 
the  Conjunctiva  (VVangemnann]). — This  disetise  is  caused  by  the 
irritation  of  caterpillar  hairs  which  have  lodgrd  in  the  conjunctiva, 
cornea,  or  iris,  and  was  first  descrilx'd  in  ISS;?  by  rMgenstcchri-.  In 
addition  to  conjunct iv.-d  congestion  and  pericorneal  injection,  the 
tliseasc  is  <liai;ictcri/,c(|  by  ;i  number  <»f  grayisli  or  ycllowisli  scjni- 
transp.'iiciii    mxlulcs,    uhicli   ;iic   located   in    the  conjunctiva   and   cpi- 


XEROPHTHALMOS  247 

sclera,  the  most  usual  situation  being  the  ocular  conjunctiva  between 
the  lower  border  of  the  cornea  and  the  fornix.  In  a  case  studied  by 
the  author  and  E.  A.  Shumway,  27  such  nodules  could  be  differenti- 
ated, those  directly  in  the  center  of  the  collection  being  somewhat 
confluent  and  assuming  a  crescentic  and  circular  appearance.  The 
lesions  strongly  suggest  tubercle  of  the  conjunctiva;  and,  indeed,  the 
disease  is  called  pseudotuberculosis  of  the  conjunctiva  by  some  authors. 
The  center  of  each  nodule  usually  contains  a  caterpillar  hair,  and  is 
surrounded  by  round  cells,  giant  cells,  and  externally  by  spindle  cells 
and  a  capsule.  It  is  not  definitely  decided  whether  the  irritation  is  a 
mechanical  one,  or  whether  it  is  due  to  some  constituent  of  the  hairs. 
Not  only  is  the  conjunctiva  affected,  but  the  hairs  may  penetrate 
the  cornea,  enter  the  iris,  and  there  form  the  nodules  which  have  been 
described.  It  is  probable  that  they  may  even  reach  the  choroid. 
The  disease  is  generally  caused  by  certain  species  of  caterpillar,  particu- 
larly Lasiocampa,  or  Bombyx  (B.  ruhi,'  B.  pini),  Liparis  (L.  jnonacha, 
L.  dispar),  etc.  In  the  case  studied  by  the  author  and  Dr.  Shumway 
the  hairs  of  the  Spilosoma  virginica  were  identified.  This  subject  has 
recently  been  elaborately  studied  by  Teuschlaender  and  by  Parker  in 
this  country.  The  treatment  should  consist  in.  excision  of  the  con- 
junctival nodules  and  the  ordinary  remedies  for  conjunctivitis.  A 
somewhat  similar  disease,  clinically  resembling  trachoma,  has  been 
described  by  Markus  as  the  result  of  the  implantation  of  plant  hairs. 

Xerophthalmos  (atrophy  of  the  conjunctiva;  xerosis)  is  the  name 
employed  by  systematic  writers  to  describe  a  dry,  lusterless,  and 
shrunken  appearance  of  the  conjunctiva,  and  is  recognized  under  two 
forms — parenchymatous  and  epithelial. 

The  former  type  results  from  cicatricial  changes  which  involve  the 
deep  layers  of  the  conjunctiva;  the  sulcus  is  obliterated,  and  the  lids, 
in  severe  eases,  are  attached  to  the  eyeball,  while  the  cornea  is  opaque. 
The  surface  of  the  conjunctiva  of  the  lids  is  smooth,  dry,  and  almost 
leathery  to  the  touch.  Granular  and  diphtheritic  conjunctivitis,  pem- 
phigus, and  essential  shrinking  of  the  conjunctiva  are  the  causes  of  the 
disorder. 

Treatment  is  of  little  avail,  but  some  comfort  may  ensue  by  instilling 
glycerin  and  water  or  by  the  local  use  of  an  emulsion  of  cod-liver  oil. 

In  the  epithelial  type  the  exposed  ocular  conjunctiva  becomes  dry 
and  has  a  lack-luster  appearance;  cheesy  flakes  form,  and  the  mem- 
brane is  greasy  and  thrown  into  folds.  A  short  bacillus  {xerosis 
bacillus)  has  been  found  in  the  secretion  of  these  cases,  but  its  patho- 
genic character  is  doubtful.  This  form  of  xerosis  sometimes  occurs  in 
epidemics,  associated  with  night-blindness,  and  is  seen  among  people 
of  poor  nutrition — for  instance,  during  prolonged  fasts — or  among 
those  whose  eyes  have  long  been  exposed  to  sunlight.  It  is  also  one 
of  the  symptoms  of  keratomalacia  in  infants.  According  to  Stephen- 
son, the  disease  is  not  rare.  Night-blindness  is  not  always  present,  but 
usually  there  are  signs  of  torpor  of  the  retina,  with  contraction  of  the 
visual  fields  and  reversal  of  the  red  and  green  fields  (see  also  page  558). 


248  DISEASES    OF    THE    CONJUNCTIVA 

The  treatment  demand:?  a  nutritious  diet,  a  southinji;  coUyrium,  dark 
glasses,  and  removal  from  the  surroundings  which  have  caused  the 
difficulty. 

Amyloid  disease  of  the  conjunctiva  is  a  rare  disorder,  mainly 
observed  in  Russia  and  Galicia,  in  which  jiale.  yellowish,  wax-like, 
friable  masses  appear,  first  in  the  retrotarsal  folds;  later  the  palpebral 
and  bulbar  conjunctiva  are  involved,  as  is  also  the  tarsus.  The  disease, 
essentially  chronic  in  nature,  may  last  for  years.  Although  amyloid 
degeneration  of  the  conjunctiva  may  follow  trachoma,  this  disease  as 
Raehlmann  pointed  out  is  not  its  cause;  it  may  arise  in  ej'es  otherwise  ! 

healthy.  Herbert  has  described  hyaline  or,  as  he  prefers  to  call  it  colloid 
degeneration  of  the  conjunctiva  and  in  this  country  it  has  been  investi- 
gated by  Bull.  Trout  and  Bedell. 

Extirpation  of  the  lesions  is  the  proper  mode  of  treatment.  Their 
structure  is  analogous  to  lymphoid  tumors  in  which  a  hyaline  degenera- 
tion may  be  found,  and  which,  in  all  probability,  is  an  antecedent 
condition  (Raehlmann,  Kubli).  But,  according  to  Fuchs,  hyaline 
degeneration  of  the  conjunctiva  may  be  distinct  from  amyloid  degenera- 
tion. The  diagnosis  can  be  made  with  certainty'  only  by  submitting 
the  tissue  to  the  iodin.test. 

Conjunctivitis  Petrificans. — In  this  rare  disease,  described  by 
Leber  in  189o,  a  number  of  irregular  white,  opaque  spots  appear  in  the 
conjunctiva,  which  are  slightly  elevated  above  the  surface  and  covered 
by  epithelium.  The  surrounding  conjunctiva  is  reddened  and  some- 
what inflamed,  and  any  portion  of  it  may  be  affected,  and  in  advanced 
stages  the  disease  may  spread  to  the  bulbar  conjunctiva  ami  the  tissue 
of  the  lids.  The  disease  may  assume  a  recurring  as  well  as  a  spreading 
nature,  and  in  any  event  is  a  chronic  one,  and  may  last  for  months  or 
even  years.  Nothing  is  known  of  the  etiology  of  the  disease,  the  white 
spots  consisting  of  deposits  of  lime  associated  with  an  organic  base. 
All  cases  thus  far  reported  have  occurred  in  youngfemales.  Recently 
Sidler-Huguenin  observed  a  case  of  this  character  in  a  hysteric  girl 
who  produced  the  lesions  by  putting  lime  into  the  conjunctival  sac, 
It  (lid  not  differ  from  the  type  orilinarily  described. 

Pterygium  is  a  peculiar,  fleshy  growth,  (fonsisting  of  hypertrophy 
of  the  conjunctiva  and  subconjunctival  tissue.  One  or  both  eyes  may 
be  affected.  Its  most  usual  situation  is  at  the  inner  side  of  the  eyeball, 
corresponding  to  the  course  of  the  internal  rectus  muscle;  more  rarely 
it  develops  at  the  outer,  and  very  exceptionally  at  the  upper  or  lower, 
part.  When  the  fan-shaped  expansion  aris(>s  from  th(>  semilunar  fold 
and  caruncle,  it  converges  as  it  approaches  tlie  cornea,  tlie  center  of 
which  it  rarely  passes. 

The  growth  is  comparatively  unconuiion  in  young  subj(>cts,  the 
average  age,  according  to  Fuchs.  being  about  forty-ei^lif ,  although 
it  often  develops  at  a  liMich  earlier  period  of  Hie.  .\ceording  to  Koliert 
Thompson,  of  .Vustialia,  ;uid  .lolui  Mrlieytioids,  of  Texas,  in  their 
regions  the  utTection  is  not  infre)|uently  encountered  in  young  sul)- 
jects.     Thompson's  youngest    patient    was  only  tifteen  yearsold.     Tlie 


1 


ECCHYMOSIS    OF   THE    CONJUNCTIVA  249 

theory  advanced  by  Arlt,  that  ulceration  at  the  margin  of  the  cornea 
should  be  regarded  as  the  primarj^  cause  of  the  affection,  is  no  longer 
tenable.  According  to  Fuchs,  pterj'gium  is  a  development  from  a 
Pinguecula,  and  like  it,  save  in  exceptional  cases,  belongs  to  the  so-called 
senile  changes  in  the  eye.  As  the  pterygium  develops,  the  characters 
of  the  Pinguecula  disappear.  Exposure  to  dust,  smoke,  wind,  and 
heat  is  the  exciting  cause,  according  to  McReynolds,  who  has  often 
seen  pterygia  both  at  the  inner  and  the  outer  canthus.  Pseudopterygia 
may  result  from  blennorrhea,  burns,  or  erosions  of  the  corneal  surface, 
the  thickened  conjunctiva  becoming  attached  to  the  corneal  lesion. 

The  treatment  consists  in  excision, 
transplantation,  strangulation  by  means 
of  ligatures,  or  evulsion  (see  page  683). 
Pinguecula  is  a  small,  yellowish 
elevation  situated  in  the  conjunctiva 
near  the  margin  of  the  cornea,  and 
usually  at  the  inner  side.  It  has  the 
appearance  of  fatty  tissue,  but  is  a 
hyaline  degeneration  of  the  connective- 
tissue  fibers  of  the  subconjunctival 
tissue,  and  should  be  regarded,  accord-    Fig.  ii4.— Large  pseudopterygium, 

,       T-i      V-  xi       /^     J.     X  •      J.I-  the  result  of  a  lime-burn. 

mg  to  tuchs,  as  the  first  stage  m  the 

development  of  a  pterygium.     It  may  be  excised  and  the  conjunctival 

wound  closed  with  a  silk  suture. 

Abscess  of  the  conjunctiva  is  a  rare  condition,  in  which  a  local- 
ized area  of  suppuration  appears  in  the  subconjunctival  tissues.  It 
may  develop  in  children  of  greatly  depressed  nutrition,  and  is  sometimes 
the  sequel  of  a  wound.  Ulcers  of  the  conjunctiva  are  occasionally  seen 
and  may  be  severe  enough  to  destroy  the  tarsus  (Cailloud).  Widmark 
and  T.  Harrison  Butler  have  described  a  form  of  conjunctival  disease 
characterized  by  congestion  of  the  inferior  tarsal  conjunctiva  and  of  this 
membrane  in  the  lower  epibulbar  expansion.  Part  or  all  of  the  affected 
area  stains  with  fluorescein.  Slight  stippling  of  the  cornea  may  be 
present.  Brow  pain  and  occipital  headache  may  precede  the  inflam- 
mation. Massage  with  a  1  per  cent,  ointment  of  yellow  oxid  of  mer- 
cury, according  to  Butler,  is  the  best  application  in  the  treatment  of 
Widmark 's  conjunctivitis. 

Ecchymosis  of  the  Conjunctiva. — This  is  an  extravasation  of 
blood  beneath  the  conjunctiva  sclerse,  the  meshes  of  the  connective 
tissue  being  filled  with  blood-clot,  and  occurs  as  the  result  of  an  injury, 
or  of  operation,  for  example  tenotomy,  or  from  some  violent,  straining 
effort — e.  g.,  during  a  paroxysm  of  whooping-cough  or  a  convulsive 
seizure  and  maj-  be  due  to  fracture  of  the  base  of  the  skull.  It  may  arise 
without  obvious  cause,  especially  in  elderly  persons,  and  has  been  seen 
in  young  girls  at  the  time  of  the  menstrual  epoch.  Its  occurrence 
during  severe  conjunctival  inflammations  has  been  described.  Recur- 
ring subconjunctival  hemorrhages  are  important  indications  of  chronic 
nephritis  and  arteriosclerosis.     They  also  occur  in  diabetes.     Ordinarily, 


250  DISEASES    (JY   THE    CONJUNCTIVA 

suljconjuiK'tiviil  henionhafic  will  suljsidc  by  abi^orption  and  requires  no 
treatment.  Hemorrhage  from  the  conjunctiva  iisuallj'  results  from  an 
injur}'  or  wound,  soniotinics  from  the  application  of  an  irritant,  p.  g., 
nitrate  of  silver  (the  author  has  leported  one  case  of  alarminji  hemor- 
rhage from  the  conjunctiva  following  Credo's  prophylaxis);  but  may 
also  appear  spontaneously  during  infectious  fevers  and  in  connection 
with  menstruation.     It  has  been  noted  in  newborn  children. 

Chemosis  (edema)  of  the  conjunctiva  occurs  where  the  connec- 
tive-tissue layer  is  distended  with  scrum,  and  is  often  associated  with  an 
inflammatory  exudation.  It  is  generally  a  symptom  of  some  other  dis- 
ease— for  example,  acute  conjunctivitis,  choroiditis,  iritis,  sinusitis,  or 
orbital  cellulitis.  Angioneurotic  edema  of  the  conjunctiva,  with  swell- 
ing and  hyperemia,  may  appear  without  any  apparent  cause  and  with 
marked  suddenness.  In  paralysis  of  the  exterior  straight  muscles  the 
overlying  conjunctiva  is  often  decidedly  edematous,  and  may  be  an 
early  symptom  of  this  condition.  Chemosis  of  the  conjunctiva  follow- 
ing the  use  of  iodid  of  potassium  has  been  reported  by  the  author,  and 
it  may  succeed  a  general  outbreak  of  urticaria. 

Treatment. — The  swollen  tissues  may  be  incised  and  an  astringent 
lotion  prescribed. 

Emphysema  of  the  conjunctiva  consists  in  a  distention  of  the 
connective-tissue  spaces  with  air.  and  occurs  under  the  same  condi- 
tions which  occasion  this  accident   when  it  involves  the  eyelids. 

Lymphangiectasis  of  the  conjunctiva  is  a  development  of  small 
blisters  in  the  conjunctiva,  filled  with  semitransparent  fluid,  and  usually 
gathered  together  in  masses.  These  are  situated  superficially,  and 
readily  move  with  the  conjunctiva  over  the  subjacent  tissue.  An  inter- 
ference with  the  natural  lymph  flow  and  consequent  distention  of  the 
lymph-spaces  is  the  probable  explanation  of  their  appearance.  The 
a'Tection  is  saidto  be  most  frequent  in  children,  but  may  occur  at  any 
age.  Spontaneous  disappearance  is  the  conmion  outcome,  but.  if  need 
be,  the  small  l)listers  may  be  incised. 

Syphilis  of  the  Conjunctiva. — Chancres  may  develop  on  the 
upper  or  lower  culdesac,  and  even  upon  the  ocular  conjunctiva,  as 
primary  a  ections,  and  not  only  as  extensions  from  the  lids.  \  few 
instances  of  soft  chancre  have  been  descril)ed. 

As  manifestations  of  general  sj'philis,  ulcerated  papular  syphilids 
and  gunnna  of  the  conjunctiva  have  been  recorded.  Mucous  patches 
occasionally  develop  on  the  conjunctiva.  Finally,  there  is  a  type  of 
inflanunation  called  suphililic  conjiinctiritis,  which  appears  as  a  stub- 
born catarrh,  or  in  the  form  of  gianuiations  similar  to  trachoma  follicles, 
in  an  anemic  and  rather  colloid-looking  conjunctiva.  The  ilisi'ase  is 
not  amenable  to  local  treatment,  but  disai)pears  under  antisyphilitic 
remedies.  Conjunctival  lesions  in  hereditary  sy|)hilis  are  unconunon; 
papidar  sy|)hilids  and  gnnnn;is  have  l)een  described. 

Tumors  and  Cysts  of  the  Conjunctiva.  As  congenital  forms, 
tr.Mnsiiiccnt  cysts,  angiomas,  caveinoiis  angiomas,  lyniiihangitMnas, 
dermoid  growths  (see  page  308),  and   pigment    spots  have  Ix'en  i\v- 


TUMOES    AND    CYSTS    OF    THE    CONJUNCTIVA  251 

scribed.  Moles  of  the  conjunctiva  are  usually  deeply  pigmented  (occa- 
sionally they  have  a  gray  or  pinkish  color) ;  rarely  they  spread  over  the 
tissue  without  involving  the  deeper  layer.  Pigment  patches,  especially 
near  the  limbus,  are  not  uncommon  in  persons  of  dark  complexion  and 
have  no  pathologic  significance.  Angiomas  may  be  situated  on  the 
palpebral  conjunctiva,  the  bulbar  conjunctiva,  the  fornix,  or  the  plica. 
Usually  congenital  in  origin,  they  may  arise  in  later  life.  A  nevus 
may  be  the  starting-point  of  a  sarcoma.  Pigment  spots,  after  healing 
of  variolous  pustules,  have  been  described.  Ncevus  pigmentosus 
also  occurs  (Wintersteiner)  and  may  give  rise  to  sarcoma.  Pigment 
patches  on  the  ocular  and  palpebral  conjunctiva  have  been  observed — 
melanosis  of  the  conjunctiva.  In  a  patient  under  the  care  of  the  author 
there  was  marked  bilateral  pigmentation  in  both  conjunctival  sacs, 
with  patches  of  pigment  in  the  semilunar  folds  and  caruncles.  He 
was  one  of  a  family  with  this  peculiarity,  which  had  existed  in  a 
number  of  generations. 

Cysts  of  the  conjunctiva  may  appear  in  the  bulbar  conjunctiva,  in  the 
palpebral  conjunctiva,  and  in  the  fornix.  Parsons  describes  the 
following  varieties:  Retention,  lymphatic,  traumatic,  parasitic,  and 
congenital  cysts.  This  materially  simplifies  Cirincione's  elaborate  classi- 
fication. Retention  cysts,  often  seen  in  the  region  of  the  retrotarsal 
folds,  are  small,  oval,  clear  bodies.  They  develop  in  new-formed  glands 
as  the  result  of  inflammation,  in  the  so-called  Henle's  glands,  and  more 
rarely  in  Krause's  glands.  They  may  also  rise  from  the  accessory 
lacrimal  gland.  Lymphatic  cj^sts  appear  in  the  bulbar  conjunctiva, 
and  represent  dilatations  of  lymphatic  vessels  (lymphangiectasis  and 
lymphangioma  (see  page  250).  Usually  multiple,  they  occasionally 
appear  as  isolated,  yellowish  cysts.  Traumatic  cj^sts  arise  as  the  result 
of  a  conjunctival  wound  or  injury,  and  sometimes  are  implantation 
cysts — that  is,  through  the  wound  epithelium  from  the  "skin,  cilia,  etc., 
gains  entrance,  degenerates,  and  produces  the  cyst.  Parasitic  cysts 
are  usually  due  to  the  presence  of  a  cysticercus,  and  appear  as  large, 
yellowish  vesicles.  A  white  spot  in  the  wall  may  indicate  the  situation 
of  the  embryo.  Filarise  may  also  cause  conjunctival  cysts.  To  a 
growth  situated  near  the  corneal  margin,  semitranslucent  in  color,  and 
often  of  congenital  origin,  Parinaud  gave  the  name  dermo-epithelioma. 
For  this  title  Oatman  preferred  the  name  "epithelial  cystoma  of  the 
conjunctiva,"  as  he  believed  it  represented  a  transitional  stage  in  the 
development  of  the  epithelial  cyst. 

Among  the  benign  tumors,  dermoids  (see  page  308), lipoma,  fibroma, 
osteoma,  granuloma,  adenoma,  hemangioma,  and  papilloma  have 
their  habitat  upon  the  conjunctiva.  Lipomas  and  lipomatous  der- 
moids are  found  (see  Fig.  119)  between  the  superior  and  the  external 
rectus.  Double  sj^mmetric  lipodermoids  at  the  inner  commissure, 
of  congenital  origin,  and  arising  from  the  plica  or  caruncle  have  been 
recorded  (Mtiller,  Vossius).  Fibromas  are  either  hard  or  soft,  and 
appear  in  the  form  of  polypi.  Soft  fibromas  occur  chiefly  in  the  fornix 
or    palpebral    conjunctiva,    and    are    often    highly    vascular.     Hard 


252 


DISEASES    OF    THE    CONJUNCTIVA 


fibromas  are  less  common,  and  arise  from  the  palpebral  conjunctiva  or 
caruncle.  Bone  formation  usually  occurs  between  the  margin  of  the 
cornea  and  the  commissure.  Papillomas  are  either  pediculated  or 
sessile,  and  histologically  resemble  the  structure  of  the  papilUe.  They 
may  arise  from  the  conjunctiva  or  plica,  and  are  often  multiple. 
Ordinarily  benign,  they  may  undergo  carcinomatous  degeneration  and 
infiltrate  the  eyelids  (Risley  and  Shumway).  Papillomas  have  been 
confounded  with  masses  of  granulation  tissue  arising  from  wounds — 
€.  g.,  after  strabismus  operations  antl  with  angiosarcomas.  Adenomas 
may  originate  on  the  conjunctival  surface  of  the  lids  from  Krause's 
and  Moll's  glands,  and  from  the  Meibomian  glands.  They  may 
develop  into  malignant  growths — adenocarcinomas. 


Fig.  115. — Epihulbarliijonia  (from  a  patient 
in  the  University  Hospital). 


Fits.  116. — Papilloma  of  the  conjunc- 
tiva (from  a  patient  in  the  Philadelphia 
General  Hospital). 


Treatment. — Usually  the  growths  described  can  i)e  readily  excised, 
and  llic  ('(Igcs  of  the  wound  may  be  united  with  fine  sutures.  In 
simple  cysts,  cutting  away  the  anterior  wall  is  generally  sufficient  to 
cause  a  cure.  Xcvi  have  been  tn^itml  with  applications  of  ethylate  of 
sodium  (Snell).  Titc  removal  of  papillomas  should  be  thorough,  as 
they  have  a  teiideiicy  to  undergo  careinoMiatous  degeneration. 

The  mahgnant  growtlis  include  epithelioma  and  sarcoma. 

Epithelioma  may  occur  as  a  primary  growth  upon  the  ocular  con- 
junctiva, especially  at  the  limbus  cornea*,  and  rarely  appears  before  the 
fortieth  year  of  life.  Conunonly  situated  at  the  outer  sitle,  it  may  also 
appear  on  the  nasal  side,  and  in  rare  instances  has  surrounded  the 
entire  cornea  or  encircled  the  glol)e  iinrihulhar  rpitlKlionni). 

The  epitlu'liomatous  or  carcinomatous  growth  usually  first  mani- 
f(!sts  itself  as  a  small,  reildish  elevation  surrounded  l>y  injectioi\. 
(jcnerally  the  growth  is  slow;  its  base  is  broad  and  attacheti  to  the 


TUMORS    AND    CYSTS    OF    THE    CONJUNCTR'A 


253 


underlying  tissue ;  rarely  a  large  fungous  mass  is  formed.  The  tumor  is 
composed  of  proliferating  masses  of  epithelium  which  proceed  from  the 
surface  epithelium,  and  are  separated  into  alveoh  by  a  connective-tis- 
sue stroma.  As  a  rule,  the  substantia  propria  of  the  cornea  is  infiltrated, 
and  if  the  growth  involves  the  eyeball,  it  does  so  along  the  perivascular 
and  perineural  lymph-sheaths.  Conjunctival  epitheUoma  may  be  pig- 
mented {melanocarcinoma) . 

Sarcoma  of  the  conjunctiva  arises  at  the  limbus  {epibulbar  sarcoma), 
its  subjects  generally  being  past  middle  life,  in  the  form  of  a  reddish- 
white  or  brownish-black  growth,  usually  overlapping  the  cornea,  but 
not  often  involving  its  structure.  Both  pigmented  and  unpigmented 
varieties  occur,  the  former  being  the  more  frequent.     The  tumors  may 


Fig.  117. — .Sarcoma  of  corneoscleral  junc- 
tion (from, a  patient  in  the  JefTerson  College 
Hospital). 


Fig.  lis. — Section  of  eyeball  (see 
Fig.  1 17)  with  sarcoma  of  corneoscleral 
junction. 


grow  rapidly  and  reach  a  large  size.  They  are  composed  of  round  and 
spindle  cells,  and  may  have  a  markedly  alveolar  arrangement  {alveolar 
sarcoma);  sometimes  the  cells  are  distinctly  epithelioid  in  type  (endo- 
thelioma). Epibulbar  sarcomas  may  develop  from  collections  of  pig- 
mented cells  on  the  conjunctiva  (pigment  spots,  melanomas).  Rarely 
they  invade  the  interior  of  the  eye.  Sometimes  they  are  multiple. 
Sarcomas  of  the  palpebral  conjunctiva  and  fornix  and  diffuse  melanotic 
sarcomas  have  been  recorded.  Angiosarcomas  of  the  conjunctiva  arise 
from  a  proliferation  of  the  adventitia  of  the  blood-vessels,  and  in  their 
growth,  like  fibromas,  they  thrust  the  epithelial  covering  in  front  of 
them.     They  have  been  mistaken  for  papillomas. 

Prognosis  and  Treatment. — Epitheliomas  vary  in  malignancy;  but 
they  tend  to  recur  even  when  superficial.  Occasionally  it  may  be 
proper  to  remove  the  growth,  with  the  expectation  of  saving  the  eye- 


254 


DISEASES    OF    THE    CONJUNCTIVA 


ball;  but  if  it  is  involved,  complete  removal  of  tiie  globe  is  indicated. 
Should  the  growth  be  excised  the  operation  should  l)e  followetl  by 
radium  applications  or  these  may  be  used  without  a  primary  excision. 
Collins  reports  the  dissipation  of  a  growth  of  this  character  after  a 
single  application  of  radium  bromid  (10  mg.)  (see  also  page  187). 
Epibulljar  sarcomas  have  been  removed  and  the  eyeball  preserved;  but 
VerhoefT  and  I.oring  I'cgard  them  as  highly  malitinant,  inasnnich  as 
there  is  a  history  of  recurrence  in  fully  80  per  cent,  of  the  cases,  and 
recommend  that  the  eyeball  should  be  removed  at  once.  Excision  of 
these  growths  is  practicable  in  the  early  stages  without  sacrificing 
th'^  eyeball.  This  excision  followed  by  radium  treatment  may 
achieve  satisfactory  results.  To  the  method  of  treating  epibulbar 
growths  by  means  of  "electric  desiccation  "  reference  has  been  made  else- 
where (page  187). 


Fig.    119.^ — -Lipomatous  dermoid  of  the 
conjunctiva:  eye  turned  up  and  in. 


Fig.  120. — Sarcoma  of  tlie  conjunc- 
tiva (from  a  patient  in  the  Philadolpliia 
General  Hospital). 


Lepra. — According  to  Lopez,  the  chief  alterations  in  the  conjunc- 
tiva produced  by  leprosy  are  anesthesia,  inflammation,  pterygia,  and 
tul)ercles.  The  anesthesia  of  the  conjunctiva  probably  determines  the 
chronic  conjunctivitis,  which  is  common.  rt(>rygia  are  frequently 
observed,  and  are  caused  by  the  action  of  external  iiritants  upon  tlu^ 
ocular  conjunctiva,  which  has  become  insensitive  under  the  intluence 
of  the  disease. 

It  is  convenient  in  this  jjlacc  to  refer  to  the  effect  of  leprosy  upon  the 
cornea,  in  which  the  lesions  are  frecjuent  and  varied.  The  tubercles 
which  form  in  the  conjunctiva  are  apt  to  attack  the  corneoscleral 
margin,  but  may  involve  the  cornea  exclusively.  A  late  manifestation 
of  the  disease  is  an  inflammation  of  the  cornea  known  as  leprous  kerati- 
tis, which  somewhat  resembles  interstitial  keratitis. 

Lupus  occurs  as  a  primary  disease,  or  extends  to  th(>  conjunctiva 
from  the  surrounding  integument.  It  appears  in  the  form  of  reil,  granu- 
lar patches  placed  upon  an  ulcerated  base.  As  the  same  microbe  is  the 
cause  of  lupus  and  tulxTculosis,  any  di  lerenc(^  existing  in  the  two  dis- 
eases occurring  in  this  situation  nuist  rest  upon  t  he  clinical  appeaiances. 


TUBERCLE  OF  THE  CONJUNCTIVA  255 

the  lupus  spot  showing  heahng  in  one  direction  and  active  ulceration  in 
another.  Those  cases  in  which  the  disease  has  spread  from  the  lid  to 
the  conjunctiva  have  especially  been  classified  as  lupus. 

Tubercle  of  the  conjunctiva  occurs  as  a  primary  and  as  a  second- 
ary affection. 

Primary  tuberculosis  of  the  conjunctiva  is  rare,  but  a  certain  num- 
ber of  instances  are  upon  record  in  which  there  was  an  absence  of 
evidence  of  tuberculosis  elsewhere,  and  in  which  there  was  no  reappear- 
ance of  the  disease  locally,  or  in  distant  organs,  after  its  removal. 
Villard  maintains  that  in  60  per  cent,  of  the  cases  he  has  analyzed  no 
initial  tuberculous  lesion  was  discovered,  and  therefore  he  does  not 
believe  in  its  endogenous  origin. 

As  a  secondary  affection  it  has  usually  appeared  in  association 
with  nasal  and  laryngeal  tuberculosis. 

According  to  Eyre,  who  adopts  Sattler's  classification,  the  disease 
may  appear  in  one  or  other  of  the  following  manifestations:  (1)  One 
or  more  miliary  ulcers  which  usually  caseate ;  (2)  grayish  or  yellowish 
subconjunctival  nodules  which  resemble  the  sago  granules  of  trachoma; 
(3)  florid  hypertrophied  papillae  and  rounded,  flattened  outgrowths  of 
granulation  tissue;  (4)  numerous  pedunculated  cock's-comb  excres- 
cences; (5)  a  distinctly  pediculated  tumor.  The  ulcers  have  uneven 
and  slightly  raised  edges,  and  their  floors  have  yellow  or  sometimes  a 
lardaceous  appearance. 

There  are  thickening  of  the  lids,  dark-red  swelling  of  the  conjunc- 
tiva, considerable  discharge,  and  occasionally  tumefaction  of  the  tear- 
sac.  The  preauricular  and  submaxillary  lymphatic  glands  of  the  same 
side  are  enlarged.  Pain  is  not  considerable  unless  the  ulceration  in- 
volves the  bulbar  conjunctiva  and  cornea  or  extends  to  the  lids. 

The  disease  should  be  distinguished  from  trachoma,  epithelioma, 
and  syphilitic  ulceration. 

Diagnosis. — In  any  suspected  case  the  real  nature  of  the  affection 
may  be  decided  by  excising  a  portion  of  the  diseased  tissue,  submitting 
it  to  microscopic  and  bacteriologic  examination,  or  by  submitting  the 
patient  to  a  test  with  tuberculin,  or  by  implanting  a  portion  of  it  in 
the  anterior  chamber  of  a  rabbit's  eye.  It  is  not  always  possible  to 
demonstrate  the  presence  of  tubercle  bacilli. 

In  trachoma  the  lymph-glands  are  not  involved  and  the  discovery 
of  the  Prowazek  bodies  (see  Fig.  108)  would  tend  to  establish  the  diag- 
nosis. 

Epithelioma  is  excluded  by  the  age  of  the  subjects,  tuberculosis 
almost  invariably  occurring  in  young  persons;  that  is,  those  under  the 
thirtieth  year  of  life. 

Prognosis. — This  depends  upon  whether  the  disease  is  primary  or 
secondary.  In  order  to  prevent  general  infection  it  is  important  to 
eradicate  the  local  lesion.  Sight  may  be  destroyed  by  involvement  of 
the  cornea. 

Treatment. — The  diseased  tissue  may  be  removed  with  a  knife  or 
curet;  the  galvanocautery  has  been  recommended.     The  subsequent 


256  DISEASES    OF   THE    CONJUNCTIVA 

treatment  should  include  the  use  of  a  coUyriuni  of  bichlorid  of  mercury, 
and  iodoform  or  aristol  powder.  Injections  of  tnbcrcuUn  TR  are  ad- 
visable, and.  according  to  Ormond  and  Eyre,  represent  a  treatment  far 
superior  to  incision  and  scraping.  Stephenson  suggests  the  trial  of  the 
x-rays.  Axenfeld  uses  a  50  per  cent,  solution  of  lactic  acid  in  the  treat- 
ment of  conjunctival  tuberculosis;  after  its  application  the  eye  is  irri- 
gated with  a  saline  solution. 

Pemphigus  of  the  conjunctiva  is  a  rare  affection  and  it  is  rather 
uncommon  to  detect  the  bulla  in  the  conjunctiva  which  are  such  a 
characteristic  manifestation  of  the  cutaneous  lesions  of  this  disease. 
Instead  of  vesicles,  membranous  exudations,  grayish-white  in  color, 
form  on  areas  of  conjunctiva  deprived  of  their  epithelium.  A  process 
of  cicatrization  and  contraction  ensues,  fresh  gray  coated  areas 
develop  in  other  portions  of  the  conjunctiva  to  be  followed  by  addi- 
tional destruction  and  cicatrization  of  the  involved  membrane. 
According  to  Michel,  the  disease  may  be  confined  to  the  conjunctiva, 
or  it  may  attack  not  only  the  conjunctiva,  but  also  the  nmcous  mem- 
brane of  the  nose,  mouth  and  pharynx,  and  the  skin.  Coincidence  of 
pemphigus  of  the  skin  and  of  the  conjunctiva  is,  however,  uncommon. 

The  course  of  the  disease  wuth  its  almost  invariable  recurrences, 
is  slow  and  may  extend  over  months  and  years  (occasionally  it  is 
stationary)  and  is  destructive  not  only  to  the  nutrition  of  the  con- 
junctiva, but  later  to  that  of  the  cornea.  The  former  undergoes  the 
cicatricial  change  which  has  been  described  and  the  latter  becomes 
opaciue  and  staphylomatous;  often  the  lids  and  eyeball  become  ad-  j 

herent  (total  symblepharon);  rarely  the  cornea  may  escape  for  long  j 

periods  of  time.     The  extreme  fetor  in  pemphigus  to  which  Stieren  j 

refers  was  most  evident  in  a  case  recently  in  the  care  of  the  author. 

Under  the  name  essential  shrinking  of  the  conjunctiva,  a  condition  of  } 

atrophy,  contraction,  and  gradual  disappearance  of  the  conjunctival  | 

culdesac  has  been  described,  during  which  the  free  borders  of  the  lids  j 

become  fixed  to  the  ball  and  the  cornea  becomes  dry  and  opaque. 
This  probably  is  a  form  of  pemphigus,  but  has  also  been  recorded  as  an 
essentially  distinct  process.  According  to  Pergens,  essential  shrinking 
of  the  conjunctiva  may  be  ])roduce(l  by  trai'homa,  jisoriasis,  xero- 
derma pi^nicnlosum,  ichthyosis,  and  lupus. 

^Treatment. — This  is  practically  unavailing.  Applications  of 
glycerin  and  water  and  other  emollients  have  been  cm|>loyed  with  th«« 
hope  of  keeping  the  conjunctiva  moist,  and  .r-rays  (Neeper)  and 
thiosinamin  (Melville  Black)  have  Ix'en  advised.  Kabliits'  conjunc- 
tiva and  human  conjunctiva  have  l)een  transplanted,  but  usually 
without  beneficial  results.  The  author  attempte«l  this  proi-i'dure  t)n 
two  patients  without  success.  The  internal  administration  of  arsenic 
has  been  recomniended  and.  as  some  (tf  the  p;itienls  ;ii'e  also  syphilitic, 
mercury,  iodid  of  pot.-issiuiu  and  arspheiiamin  >hnuld   be  tried. 

Injuries  of  the  Conjunctiva. — (a)  Foreijin  Bodies.  A  small 
jiarticN'  of  coal,  ash,  or  dust  is  easily  removi'd  if  lodged  up»»n  the  lower 
|)ortion  <jf  the  conjunctiva;  but  if  it  linds  its  way  beneath  tiie  upper 


AFFECTIONS    OF    THE    CARUNCLE  257 

lid,  and  is  situated  far  back  under  the  retrotarsal  fold,  it  may  not  come 
into  view  when  the  lid  is  everted  unless  the  fold  is  pushed  into  promi- 
nence. If  the  foreign  body  is  attached  to  the  tissues  it  may  be  neces- 
sary to  dislodge  it  with  the  point  of  a  needle  or  with  a  spud.  Cocain  or 
holocain  will  render  this  operation  painless. 

(h)  Wounds. — These  may  be  part  of  a  serious  injury  involving 
the  lid  or  deeper  structures  of  the  eye;  more  rarely  they  occur  as  simple 
lacerations,  confined  usually  to  the  bulbar  portion.  In  suitable  cases, 
after  proper  cleansing,  the  lips  of  the  wound  should  be  drawn  together 
with  a  few  sutures. 

(c)  Burns. — These  are  commonly  inflicted  with  lime  (mortar  or 
quicklime),  molten  metals,  powder  and  acids,  and  are  especially 
serious  because  of  the  deformity  which  the  subsequent  contraction  is 
likely  to  produce,  or  on  account  of  the  development  of  a  symblepharon 
(see  page  191).  Ulceration  of  the  cornea,  hypopyon,  and  even  panoph- 
thalmitis may  result.     The  prognosis  of  such  injuries  is  always  grave. 

All  foreign  substances  must  be  removed  at  once,  and  if  lime  has 
been  the  injuring  agent,  this  is  best  accomplished  by  forcible  irrigation 
of  the  conjunctival  sac  with  clean  water.  Schmidt-Rimpler,  however, 
prefered,  in  these  circumstances,  thorough  cleansing  of  the  eye  with  oil 
introduced  with  a  syringe  into  the  culdesac.  For  acid  burns  an  alka- 
line lotion  is  usually  recommended.  The  subsequent  treatment  con- 
sists in  the  instillation  of  olive  or  castor  oil,  and  atropin  drops  to 
prevent  secondary  iritis  if  the  cornea  is  much  inflamed;  atropin  may  be 
incorporated  with  liquid  vaselin  and  placed  in  the  culdesac.  To 
prevent  the  formation  of  symblepharon  the  adhesions  forming  between 
the  bulbar  expanse  and  inner  surface  should  be  daily  parted  by  means 
of  a  blunt  probe.  As  soon  as  the  wounded  surface  is  clean  and  granula- 
tions are  visible  an  epidermic  or  mucous  membrane  graft  may  be 
adjusted  (Wilder).  Denig  recommends  immediate  interference  and 
after  removal  of  the  detritus  and  burned  conjunctiva  plants  a  mucous 
membrane  graft.  Powder  grains  are  frequently  embedded  in  the 
conjunctiva;  they  cannot  be  picked  from  their  beds;  usually  the 
larger  ones  can  be  excised. 

Affections  of  the  Caruncle. — The  caruncle  and  semilunar  fold 
may  be  swollen  in  conjunction  with  a  general  inflammation  of  the  con- 
junctiva, but  also  may  undergo  localized  enlargement  and  inflamma- 
tion, to  which  the  name  encanthis  has  been  applied,  and  which  is 
subdivided  by  systematic  writers  into  an  acute  or  inflammatory  and  a 
chronic  variety.  The  process  may  go  on  to  the  formation  of  a  minute 
abscess. 

Swollen  caruncles  are  commonly  found  in  patients  with  eye-strain, 
especially  with  imperfect  amplitude  of  convergence.  The  small  body 
is  red,  elevated,  and  angry  looking,  and  injected  vessels  run  from  it 
toward  the  cornea  in  the  interpalpebral  space.  The  condition  might 
be  designated  symptomatic  or  junctional  encanthis. 

In  like  manner,  temporary  irritation  of  the  structure  is  caused  by 
the  lodgment  upon  it  of  a  foreign  body,  or  by  the  presence  of  misplaced 

17 


258  DISEASES    OF   THE    CONJUNCTIVA 

cilia  which  rub  against  it.  The  caruncle  should  be  carefully  examined 
when  patients  complain  of  irritation,  lacrimation,  and  inability  to  use 
their  eyes  with  comfort. 

The  excessive  development  of  the  hairs  normally  placed  upon  the 
caruncle  is  called  trichosis  caruncula'.. 

A  number  of  tumors  situated  upon  and  growing  from  the  caruncle 
have  been  recorded;  in  two  instances  the  growth  proved  to  be  an  ade- 
noma (Prudden  and  Schirmer).  Primary  sarcoma  (Veasey,  Snell)  and 
carcinoma  of  the  caruncle  (malignant  encanthis)  have  been  described. 
Papilloma,  dermoids,  nevus,  fibroma,  lymphangioma,  epithelioma, 
cylindroma,  angiosarcoma,  and  lymphosarcoma  have  also  been  re- 
ported (V.  Berl). 

Treatment. — Local  irritations  of  this  body  may  be  relieved  by  the 
direct  application  of  a  mild  astringent  like  alum,  or  soothed  by  touching 
it  with  tincture  of  opium.  Foreign  bodies,  stiff  hairs,  and  misplaced 
cilia  must  be  extracted.     A  tumor  should  be  removed  by  excision. 

Argyria  Conjunctivae  (Argyrosis). — ^Long-continued  application 
of  solutions  of  nitrate  of  silver  to  the  conjunctiva  may  be  followed  by  a 
brownish  discoloration  of  this  membrane.  For  this  reason  it  is  inadvis- 
able to  allow  patients  to  use  at  home  even  a  weak  collyrium  of  this  drug. 
The  same  discoloration  follows  the  injudicious  use  of  protargol,  argyrol, 
and  largin;  indeed,  these  drugs  produce  the  stain  more  quickly  than 
nitrate  of  silver,  even,  it  is  said,  after  a  few  weeks  of  their  employment. 
The  coloration  is  due  to  staining  of  the  elastic  fibers;  the  ei)ithelium  is 
free  from  pignuMit.  Argyrosis  from  nitrate  of  silver  is  practically  irre- 
mediable, althougli  the  use  of  dionin  is  said  to  decrease  its  intensity 
(Lebensohn).  Argyrosis  from  argyrol  decreases  after  a  discontinuance 
of  the  drug  (Krauss).  A  collyrium  of  iodid  of  potassium  (O.a  per  cent.) 
may  be  tried.  A  yellowish-brown  discoloration  of  the  conjunctiva, 
known  as  siderosis  conjunctivce,  due  to  the  i)rolonged  use  of  sulphate  of 
iron,  has  been  rei)orted. 


CHAPTER  VII 
DISEASES  OF  THE  CORNEA  * 

Under  the  general  term  keratitis  are  included  divers  forms  of  in- 
flammatory affections  of  the  cornea,  to  which,  according  to  the  type, 
certain  well-marked  stages  belong;  cellular  infiltration  in  the  layers  of 
the  cornea  going  on  either  to  absorption  or  to  the  formation  of  pus;  loss 
of  the  substance  of  the  cornea  lying  over  the  infiltrated  area,  and  the 
development  of  an  ulcer;  loss  of  the  transparency  of  the  superficial 
corneal  layers  over  an  infiltrated  area,  which  has  been  converted  into 
pus  and  created  an  abscess,  with  the  final  destruction  of  these  layers  by 
the  development  of  the  abscess;  the  appearance  of  vessels  in  the  cornea; 
and  the  process  of  repair  after  loss  of  substance,  or  the  period  of 
cicatrizatio7i. 

In  many  types  of  keratitis  both  suppurative  and  non-suppurative, 
the  corneal  lesion  is  not  alone  in  evidence;  iritis,  iridocyclitis,  exuda- 
tion into  the  anterior  chamber  or  hypopyon  are  frequent  complications. 
The  usual  subjective  symptoms  include  diminution  of  vision,  pain, 
photophobia,  excessive  lacrimation,  and  blepharospasm. 

Although  it  is  customary  to  divide  the  many  tj^pes  of  corneal  in- 
flammation into  suitable  groups,  it  is  by  no  means  possible  to  refer  the 
disease  in  each  instance  to  one  or  other  of  these  divisions. 

Phlyctenular  Keratitis  or  Keratoconjunctivitis  (Eczema  of  the 
Cornea). — This  disease  is  characterized  by  the  formation  of  single  or 
multiple  phlyctenules  on  some  portion  of  the  cornea,  and  is  accom- 
panied by  dread  of  light,  excessive  lacrimation,  and  blepharospasm. 

Causes. — The  disease  is  commonly  seen  in  so-called  scrofulous  sub- 
jects, rarely  before  the  first  year  of  life,  most  frequently  in  children 
before  the  age  of  puberty,  and  less  commonly  in  adults.  It  often  is 
secondary  to  phlyctenular  conjunctivitis  or  is  associated  with  it  (see 
page  224).  Enlarged  Ijmiphatic  glands,  prominent  and  swollen  lips, 
and  diseases  of  the  joints  and  bones  may  be  present. 

This  form  of  keratitis  is  in  close  connection  with  obstructive  (ade- 
noid vegetations)  and  inflammatory  diseases  of  the  nasal  passages,  and 
an  infectious  rhinitis  is  frequently  an  associated  disorder;  ethmoiditis 
and  infected  tonsils  may  be  present.  The  cUnical  connection  between 
this  disease  and  eczema  is  intimate,  and  eczema  of  the  face,  scalp  and 
around  the  nares  is  often  an  accompanying  condition.  The  affection 
not  uncommonly  follows  in  the  wake  of  measles  or  other  acute  exan- 
themata, and  is  distinctly  under  the  influence  of  climate,  being  aggra- 
vated in  warm  and  moist  weather.  Tuberculosis  of  the  lymphatic 
glands  is  present  in  fully  one-half  of  its  subjects,  and  the  evidence  is 
daily  increasing  that  phlyctenular  keratitis  is  closely  connected  with 

259 


260  DISEASES    OF    THE    CORNEA 

tuberculosis  and  i)rol)ably  caused  by  it.  A  large  number  of  the  sub- 
jects of  phlyctenular  disease  (88  per  cent.,  G.  S.  Derby,  Stock;  90  per 
cent.,  Gibson)  react  to  tuberculin — a  suggestive  fact,  although  it  does 
not  prove  that  tuberculosis  is  the  cause  of  the  disease.  Phlyctenules 
not  infrequently'  have  developed  as  the  result  of  the  Calniette  reaction 
and  have  also  followed  subcutaneous  injections  of  tuberculin.  W. 
Stanley  Gibson,  who  has  produced  phlyctenules  experimentally  in 
tuberculous  rabbits,  as  the  result  of  a  careful  examination  of  92  patients 
with  piih'ctenular  keratoconjunctivitis  maintains  positively  that  all 
the  evidence  points  to  tuberculosis  as  the  cause  of  this  disease. 

Staphylococcus  pyogenes  aureus  and  albus  are  present  in  the  epi- 
thelium of  the  affected  regions;  but  these  organisms  are  not  found  in 
fresh  phlj'ctenules.  Tubercle  bacilli  have  not  been  discovered.  The 
exact  cause  of  the  ocular  lesions,  or  phylctenular  eruption,  has  not 
been  determined. 

Symptoms. — The  phh'ctenules,  which  consist  in  the  early  stage  of 
minute  subepithelial  collections  of  round  cells,  appear  upon  the  cornea 
usually  at  or  near  the  corneoscleral  junction.  They  vary  in  size  from  a 
poppy-seed  to  a  millet-seed;  their  tops,  at  first  gray,  speedily  grow 
yellow,  break  down,  and  form  superficial  ulcers.  They  are  accompa- 
nied by  decided  local  congestion,  increased  lacrimation,  and  photo- 
phobia. 

The  palpe])ral  conjunctiva,  always  hyperemic,  may  remain  trans- 
lucent and  bathed  in  tears,  or  the  disorder  may  be  complicated  with 
mucopurulent  conjunctivitis  or  phlyctenules  scattered  over  the  con- 
junctiva may  be  present  (page  224). 

When  the  photophobia  is  severe,  the  child  buries  its  head  deeply  in 
the  bed-clothes;  the  lids  are  spasmodically  closed,  rend(>ring  inspection 
of  the  eye  difficult,  at  times  well-nigh  impossible.  The  dread  of  light 
and  the  blepharospasm  are  probably  due  to  direct  irritation  of  the 
corneal  nerves,  as  Iwanoff  found  the  cellular  infiltration  situated  along 
their  course. 

The  pustule,  when  it  breaks  down,  forms  a  phlyctenular  ulcer. 

This  may  remain  at  its  original  seat  near  the  margin,  or  creep  toward 
the  center  of  the  cornea  (niiyratory  pustule),  followed  by  a  bunille  of 
thickly  crowded  blood-vessels,  and  form  a  sp<'cial  type  of  corneal  in- 
Hanmiation,  known  as  fascicular  keratitis.  The  blood-vt^sels.  when 
the-ulcer  heals,  disappear,  but  a  stripe  of  opacity  remains. 

Under  the  name  phlyctenular  marginal  keratitis  a  variety  of  this 
disorder  exists,  characterized  by  the  development  of  nunierous  phlyc- 
tenuh's  along  the  rim  of  the  cornea,  giving  rise  1o  a  i)roffss  whicii 
may  cease  here,  or  which,  by  further  invasions,  may  produce  vascular 
ulcers. 

More  dangerous  than  any  of  the  other  varieties  is  the  formation  of  a 
single  pustule,  just  at  the  corneal  border,  which  speedily  \dcerates  and 
is  sun-ounded  by  a  yellow  area  of  iiitilt  i;it  ion,  with  a  stiong  tendency 
to  perforate  the  coine;il  layers. 

ll     these    iiillaiiuii:it  ions    iceiir    const  aiil  Iw     the    cornea    lieconu's 


PHLYCTENULAR    KERATITIS    OR    KERATOCONJUNCTIVITIS    261 

clouded,  uneven  from  loss  of  epithelium,  and  covered  with  numerous 
superficial  vessels,  the  whole  forming  the  so-called  phlyctenular 
pannus. 

Sometimes  in  the  middle  and  deep  layers  of  the  cornea  extensive 
gray  or  yellow  opacities  may  form,  which  may  suppurate  with  large 
loss  of  tissue,  or  go  on  to  resorption.  These  are  the  so-called  deep 
scrofulous  infiltrations. 

Pathology. — The  efflorescence  or  phlyctenule  consists  of  a  collection 
of  lymphoid  cells,  hang  between  Bowman's  membrane  and  the  epi- 
thelium, by  the  softening  of  which,  as  before  described,  the  superficial 
cells  are  discharged,  and  an  open,  ulcerating  surface  is  exposed.  By 
further  degeneration  the  entire  nodule  disappears,  and  the  loss  of  sub- 
stance is  rapidly  replaced  with  epithelium. 

Diagnosis. — This  presents  no  difficulties,  direct  inspection  render- 
ing the  nature  of  the  disease  evident. 

Prognosis. — The  course  varies  greatly;  in  mild  cases  healing  takes 
place  with  only  a  slight  loss  of  substance,  and  the  resulting  scar  is 
scarcely  discernible. 

Not  so  with  the  severe  forms,  in  which  there  has  been  decided  loss 
of  substance  and  a  distinct  scar-tissue  remains,  or  in  which  deep  ulcera- 
tion with  perforation  occurs,  or  where  constantly  recurring  ulceration 
leaves  an  uneven  and  roughened  surface.  In  children  of  the  tubercu- 
lous type,  especiallj'  if  theu-  surroundings  are  unfavorable,  phlj'ctenular 
keratitis  is  exceedingly  intractable. 

Treatment. — In  order  to  make  a  thorough  application  of  the  local 
remedies  the  child's  head  should  be  taken  between  the  surgeon's  knees 
and  the  lids  separated,  while  the  attendant  holds  the  hands  and  body; 
the  cornea  will  usually  roll  out  of  sight,  but  gradually  may  be  coaxed 
into  view.  Sometimes  a  Ud-elevator  is  useful,  and  a  few  whiffs  of  ether 
or  chloroform  ma}'  be  necessary. 

If  much  secretion  is  present,  boric  acid  or  physiologic  salt  solution 
should  be  employed,  and  atropin  drops  should  be  instilled  with  suffi- 
cient frequency  to  maintain  mydriasis.  Qocaia,  judiciously  used,  will 
allay  the  photophobia,  but  its  continuous  application  where  corneal 
ulcers  exist  is  to  be  deprecated.  Holocain  is  sometimes  useful;  dionin 
occasionally  seems  to  act  unfavorably  in  phlyctenular  keratitis.  An 
ointment  of  the  yellow  oxid  of  mercury,  gr.  i  to  5J10-06o  — 3.885ugJiu), 
either  with  or  witHoul,  tlieaddition  of  atropin,  may  be  emploj'ed,  or 
calomel  be  dusted  into  the  conjunctival  sac,  provided  no  form  of  iodin 
is  being'exhibiTeTt-(5ee  page  225).  '^The  eyes  should  be  protected  if 
possible  with  goggles,  and  the  child  encourged  not  to  bury  its  head  in 
the  bedclothes  (see  also  page  270). 

Douching  the  eyes  with  cold  water  will  subdue  the  dread  of  light, 
and  touching  the  ulcerated  external  commissure,  which  almost  invari- 
ably exists  in  these  cases,  with  a  crystal  of  bluestone,  as  Roller  has 
suggested,  helps  to  relieve  the  blepharospasm.  In  severe  cases  the 
ulcerated  fissure  may  be  incised,  or  the  lids  may  be  forcibly  separated. 
No  doubt  this  acts  by  stretching  or  rupturing  a  few  fibers  at  the  com- 


262  DISEASES    OF    THE    CORNEA 

missural  angle,  and  relieves  the  spasm  in  the  same  manner  as  a  similar 
manipulation  is  efficacious  in  fissure  of  the  anus. 

The  best  possible  hygienic  surroundings  must  be  obtained,  with  fresh 
air  and  wholesome  food.  Tea,  coffee  and  sweets,  that  is  cake,  candy, 
pastry,  etc.  must  be  strictly  forbidden.  A  proper  diet  in  this  affection 
is  of  paramount  imj)ortance.  Cod-liver  oiljiron,  <ii>j>ecially  syrup  of  the 
iodid  of  iron,  syrup  of  hydriodic  acid,  quinin^  often  suitably  given  with 
pepsin,  and  arsenic  are  the  gaost  acceptable  internal  remedies. 

rheHrine-  should  be  examined  in  all  these  cases;  and  scrupulous 
attention  to  the  condition  of  the  alimentary  canal  is  an  important 
factor  in  the  treatment.  The  administration  of  calomel  in  small 
doses,  persistently  used,  is  of  real  value. 

If  rhinitis  is  present,  a  powder  composed  of  equal  parts  of  pulver- 
ized camphor,  boric  acid,  and  siibnitrate  of  bisnuith  is  useful  (Augag- 
neur),  especially  if  the  parts  are  thoroughly  cleansed  ^^^th  Dobell's 
solution  before  its  insufflation  into  the  nasal  chambers;  powdered  iodo- 
form ma}'  be  used  in  like  manner,  but  its  odor  is  objectionable,  hence 
nosophen  is  preferable,  and  borobismuth  ointment  is  recommended. 
The  a^ected  mucous  membrane  may  be  painted  with  compound  tinc- 
ture of  benzoin  or  sprayed  with  permanganate  of  potassium  (1:  oOOO). 
If  possible,  however,  this  part  of  the  treatment  should  be  confided  to 
an  expert  rhinologist.  Removal  of  adenoids,  or  of  infected  tonsils  is 
often  urgently  needed.  That  ethmoiditis  may  be  present  is  well  known . 
The  teeth,  too  often  neglected  in  children  with  this  disease,  recpiire 
special  consideration.  A  patulous  condition  of  the  lacrimal  passages 
should  be  secured. 

In  stubborn  forms  of  recurring  vascular  ulcer  and  deep  ulceration, 
especially  in  the  fascicular  type,  the  use  of  the  actual  cautery  in  the 
manner  later  desciib(>d  is  ))rodu('tive  of  excellent  results,  or  the  ulcer 
may  be  touched  witli  trichloracetic  acid.  In  general  terms,  the  treat- 
ment of  severe  types  of  phlyctenular  ulcer  is  the  same  as  that  recorded 
on  pages  272-273.  In  phlj^ctenular  pannus  peritomy  is  sometimes  a 
useful  procedure,  and  canthophisty  may  be  necessary. 

The  best  results  in  the  treatment  of  phlyctenular  disease  are  s(>cured 
if  its  subjects  are  treated  like  other  cases  of  tuberculosis — viz.,  after 
the  patient  is  instructed  as  to  general  living,  proper  food,  etc.,  lie  is 
visited  in  his  home  l)y  one  of  the  class-workers  in  the  st)cial  service  of 
the  hospital,  and  is  shown  how  to  live  and  helped  to  carry  out  all 
directions.  'I'his  metiiod,  advocated  by  (jeorge  Derby,  the  author 
has  followed  with  satisfaction  in  his  hospital  patients.  Tuberculin 
therapy  may  be  tried;  certain  observations  indicate  that  it  tends  to 
I)revent  the  relapses  which  are  so  common  in  this  disonler.  Aft(>r 
healing,  provided  the  condition  of  th(>  coi-nea  permits  it,  refractive 
error  siiould  be  corrected. 

In  general  terms,  phlyctenular  inllanunat  ion  of  I  he  cornea,  which  has 
just  b(M*n  described,  is  :i  eiicumscrilx'd,  usually  superficial  keratitis, 
and  is  known  under  a  variety  of  synonyms  lyin|)hatic,  scrofulous, 
vesicular,  fascicular,  and  pustular     and  where  it  appeals  in  adults  as- 


f 


I 


ULCERS    OF    THE    CORNEA  263 

sumes  the  form  of  a  simple  corneal  infiltration.  It  furnishes  the  great- 
est number  of  ulcers  of  the  cornea  which  are  found  in  early  life,  and  also 
a  large  group  of  those  ulcers  which  are  of  -primary  origin — i.  e.,  where 
the  disease  starts  in  the  cornea,  the  remainder  of  the  group  being 
caused  by  injury,  abscess,  depressed  nutrition,  etc.  The  entire  series 
is  in  contrast  to  secondary  ulcers — i.  e.,  where  the  disease  follows  as  the 
result  of  a  severe  inflammation  of  the  conjunctiva — e.  g.,  purulent, 
diphtheritic,  or  granular  conjunctivitis. 

The  remaining  inflammations  of  the  cornea  are  divided  by  system- 
atic writers  into  ulcerative  (or  suppurative)  and  non-ulcerative  (or  non- 
suppurative) inflammations. 

Ulcers  of  the  Cornea. — If  the  stage  of  infiltration  fails  to  termi- 
nate in  absorption  and  there  is  destruction  of  the  overlying  corneal 


Fig.   121. — Perforatiug  ulcer  of  the  cornea  with  incarceration  of  iris  (from  a  photomicro- 
graph) . 

tissue,  an  ulcer  results.  Surrounding  the  area  of  necrotic  tissue  is  a 
clear  space,  and  beyond  this  a  ring  of  infiltrating  leukocytes  which  come 
from  the  vessels  at  the  edge  of  the  cornea.  In  favorable  cases  this 
necrotic  tissue  is  thrown  oS,  the  surrounding  cornea  clears,  the  ulcer  is 
covered  by  a  proliferation  of  the  epithelium,  and  the  loss  of  substance 
is  replaced  by  connective  tissue  derived  from  the  fixed  cells  of  the 
cornea.  Where  the  process  is  progressive,  successive  layers  of  the 
cornea  become  involved,  the  iris  and  ciliary  body  are  involved,  and 
hypopyon  forms  (see  page  265).  If  the  ulceration  is  not  checked,  the 
cornea  is  perforated,  and  inclusion  of  the  iris  may  result  in  staphyloma 
(see  page  280).     If  the  iris  does  not  prolapse,  the  perforation  may  be 


264  DISEASES    OF   THE    CORXEA 

closed  with  a  tissue  produced  by  proliferation  of  the  posterior  hninp; 
endothehum.  Bowman's  and  Desceniet's  membranes  are  never 
reproduced. 

In  addition  to  those  which  have  been  described  with  phlyctenuhir 
keratitis,  corneal  ulcers  may  be  gathered  into  several  groups: 

1.  Simple  ulcer  appears  in  the  form  of  a  small,  superficial,  gray 
lesion,  associated  with  slight  pericorneal  va.scularity,  and  results  from 
the  rupture  of  a  phlyctenule  ("pimple  ulcer")  or  from  trauma. 

An  ulcer,  which,  from  its  situation,  is  called  sinall  central  ulcer, 
may  develop  as  a  gray  or  gray-white  opacity  in  the  center  of  the 
cornea,  and  is  not  accompanied  with  much  vascularity  or  dread  of 
light.  The  elevation  is  sUghtl}'^  cone  shaped  until  the  whitish  top 
breaks  down  into  a  shallow  depression. 

Usually  single,  this  form  of  ulcer  may  be  multijile,  and  tends  to 
recur.  It  is  seen  in  young  children  who  have  been  poorly  nourished 
and  are  of  a  so-called  strumous  habit.  While  healing  generally  occurs 
with  promptness,  a  permanent  opacity  may  remain,  which,  from  its 
central  situation,  may  serously  impair  vision.  If  neglected,  and  in  pa- 
tients of  poor  nutrition,  this  ulcer  occasionally  forms  an  al)scess  of  the 
cornea,  or  changes  its  type  and  develops  into  the  following  variety: 

2.  Purulent  oi-  deep  ulcer  consists  of  an  area  of  yellowish  ( purulent) 
infiltration,  surrounded  by  a  zone  of  hazy  cornea,  round  or  irregular  in 
shape,  centrally  excavated,  and  with  a  tendency  to  travel  inwaril  until 
perforation  occurs,  but  not  to  extend  in  a  lateral  direction.  Like  all 
severe  types  of  corneal  ulceration,  it  may  be  associated  with  intlanuna- 
tion  of  the  iris  and  the  formation  of  pus  in  the  anterior  chamber;  if 
perforation  takes  place,  an  adherent  scar  or  leukoma  results. 

This  ulcer  is  either  primary  from  injury,  and  sonu>times  contains 
a  foreign  body  as  its  nucleus,  or  is  secotidary  to  a  violent  grade  of 
conjunctival  inflammation.  The  subjective  symptoms  are  pain,  brow- 
ache,  congestion,  and  sometimes,  though  not  necessarily,  photophobia. 

3.  Indolent  ulcer  (absorption  ulcer)  occurs  under  several  forms:  (a) 
Shallow  central  ulcer,  with  slightly  turl)id  base,  unattended  with  any 
coiisi(l('ral)le  pain  or  photophobia,  essentially  chronic  in  its  course,  and 
healing  finally  with  a  faintly  opaque  facet  {faceted  nicer). 

(b)  Excavated  or  gouged-out  ulcer,  often  seen  in  cliildicii.  most 
troublesome  because  it  is  rebellious  to  treatment,  has  its  seat  ni>ar  the 
corneal  margin.  It  may  be  entirely  overlooked  on  account  of  the  ab- 
sence of  congestion,  and  because  in  appearance  it  is  a  small,  punched- 
out  excavation  with  transparent  bottom,  and  free  from  any  opatiU(> 
surrounding.  The  floor  of  the  ulcer  loses  its  transhicency  when  heal- 
ing is  about  to  take  place,  and  a  few  ves.sels  of  repair  pass  to  its  margin. 

(c)  Reparatire  ulcers  are  seen  when,  as  occasionally  occurs  in  the 
course  of  the  healing  of  an  ordinary  corneal  ulcer,  this  lo.«<es  its  turbi»lity 
and  assumes  a  clear,  facet-like  appearance.  The.se  are  similar  to  the 
al)s<)rption  ulcers  which  occur  primarily,  and  which,  unattfiided  with 
injection  and  with  local  symptoms,  may,  none  the  less,  extend  inu.-ird 
and  perforate  the  cornea. 


ULCERS    OF    THE    CORNEA 


265 


Indolent  ulcers,  in  general  terms,  may  depend  upon  some  failure  in 
the  nutrition  of  the  cornea  due  to  neuropathic  disturbance.  They  are 
found  in  anemic  and  scrofulous  subjects,  and  are  seen  in  cases  of 
chronic  trachoma.  Central  ulcers  may  also  arise  in  association  with 
or  after  Koch-Weeks  and  pneumococcus  infections.  Because  of  the 
central  situation  of  the  small  cicatrix  (macula)  which  remains  vision 
is  often  greatly  disturbed  by  the  production  of  irregular  astigmatism. 

4.  Infected  or  Sloughing  Ulcer  {Purulent  Keratitis). — Ulcers  with- 
out vessels  of  repair,  which  spread  widely  from  one  border  and  readily 
become  complicated  with  hypopyon  and  iritis,  and  which  are  often 
the  result  of  a  trifling  injury,  usually  affect  elderly  persons  and  those 
whose  nutrition  is  depressed. 

The  most  important  type  of  these  is  the  acute  serpiginous  or  creeping 
ulcer  of  Saemisch.  In  the  beginning  a  nearly  central  gray  area  forms, 
which  ulcerates;  its  margins  are  sharp,  and  one,  assuming  the  form  of 
an  elevated  curve,  is  more  decidedly  opaque  or  yellow  than  the  others, 
and  is  known  as  the  arc  of  propagation.  Immediately  behind  it,  the 
ulcer  with  its  gray  floor  seems  deeper  than  the  portion  next  to  the  cor- 
neal margin. 

The  surrounding  cornea  is  opaque,  and 
the  lesion  spreads  rapidly,  at  the  same  time 
growing  deeper;  iritis,  iridocyclitis,  and 
hypopyon  ensue,  and  perforation  and  ex- 
tensive sloughing  of  the  cornea  are  likely  to 
occur.  Usually  the  patient  complains  of 
severe  brow-pain  and  the  eye  is  intensely 
tender.  Vision  is  reduced  to  mere  light 
perception.  In  other  cases,  while  the  local 
lesion  is  severe,  the  subjective  symptoms  of 
inflammation  are  almost  absent.  Kipp 
called  attention  to  certain  types  of  infected 
ulcer  from  the  margin  of  which  straight,  or 
nearly  straight,  lines  diverge  in  all  direc- 
tions obliquely  through  the  parenchyma  of 
the  deepest  layers,  their  ends  being  con- 
nected by  intermediate  strise.  They  may 
be  due  to  folds  in  Descemet's  membrane 
or  to  cell  infiltration. 

Hypopyon,  to  which  reference  has  just  been  made,  may  be  seen 
with  both  small  and  large  ulcers,  and  consists  of  a  collection  of  pus  in 
the  anterior  chamber,  varying  in  extent  from  a  mere  line  to  a  quantity 
which  well-nigh  fills  the  chamber. 

This  appears  as  a  yellow  mass  at  the  bottom  of  the  anterior  cham- 
ber, and  is  bounded  above  by  a  horizontal  margin.  If  the  collection  is 
fluid,  its  position  will  shift  with  movements  of  the  head;  if  it  is  tena- 
cious, no  movement  can  be  observed.  The  pus  is  caused  by  an  aggre- 
gation of  leukocytes  derived  from  the  vessels  about  the  periphery  of 
the  cornea  and  from  those  in  the  inflamed  ciliary  body  and  iris,  the 


Fig.  122. — Infected  ulcer  of 
the  cornea,  with  hypopyon^ — ■ 
hypopyon-keratitis  (modified 
from  Haab). 


266  DISEASES    OF    THE    (  ORNEA 

endothelium  of  which  is  cast  oT.  In  other  words,  the  pus  in  hypopyon 
does  not  come  from  the  cornea.  The  changes  which  take  place  at  the 
posterior  surface  of  the  cornea,  that  is,  pus  corpuscles  derived  as  already 
explained  and  which  accumulate  at  a  point  corresponding  to  the  ulcer, 
penetrate  Descemet's  membrane  and  invade  the  cornea,  constitute  an 
important  factor  in  the  perforation  of  the  cornea  which  so  frequently 
occurs  (Fuchs).  Sometimes  Descemet's  membrane  is  ruptured  with- 
out perforation  of  the  cornea,  and  the  pus  in  the  cornea  and  in  the 
anterior  chamber  are  in  direct  connection. 

The  combination  of  ulcer  of  the  cornea  and  pus  in  the  anterior 
chamber  has  received  the  name  hypopyon  keratitis,  which  generally  is 
limited  to  the  type  described  as  infective  or  creeping  ulcer. 

Causes  of  Infected  or  Sloughing  Ulcers. — The  investigations  of  Uht- 
hoff  and  Axenfeld  have  demonstrated  that — (1)  Typical  serpiginous 
ulcer  of  the  cornea  with  hypopyon  is  nearly  always  caused  l)y  the  pneu- 
mococcus  (Frankel-Weichselbaum  capsulated  diplococcus) ;  this  micro- 
organism may  frequently  be  found  in  these  ulcers  in  almost  pure 
cultures.  These  ulcers  are  also  caused  by  the  diplobacillus  of  Morax 
and  Axenfeld  {diplohacillary  ulcers),  the  bacillus  of  Petit,  the  Bacillus 
subtilis  (Zur  Nedden),  and  the  streptococcus.  (2)  Sloughing  ulcers 
not  typically  serpiginous  are  caused  by  infection  with  staphylo- 
cocci, streptococci,  and  by  mixed  infection.  Occasionally  pneumococci 
originate  ulcers  which  are  not  characteristically  creeping;  they  may  be 
variously  disposed  in  the  center,  periphery  and  intermediate  zones  of 
the  cornea.  (3)  In  addition  to  the  micro-organisms  mentioned,  the 
following  bacteria,  according  to  Uhthoff ,  have  been  found  to  be  the  cause 
of  various  forms  of  infected  ulcer:  Pfeiffer's  capsulated  bacillus, 
Bacillus  pj'Ogencs  fcBtidus,  Bacterium  coli.  Bacillus  ]\vo('yaneus, 
diplobacillus,  pneumobacillus,  ozena  bacillus,  tubercle,  and  lepra 
bacillus.  Other  unidentified  varieties  have  also  been  found,  and  corneal 
ulceration  has  also  been  ascribed  to  streptothrix  (De  Bernardinis). 

Infected  ulcer  due  to  BaciUus  pyocynneus,  as  a  rule,  is  a  malignant 
process.  Preceded  b}'  supeificial  keratitis  a  deep  lesion  dev(>U)ps,  with- 
out the  crescentic  shape  of  the  serpiginous  ulcci-  ami  containing  pus. 
chiefly  in  its  center.  The  diagnosis  depends  upon  a  l)a('t(Miologic 
examination. 

5.  Mycotic  Keratitis  (Kcrnloniycosis  AspcnjiUiiKi).  In  a  snuiU  per- 
centage of  cases  of  sloughing  keratitis  tiie  infection  is  due  to  a  mold  - 
Aspergillus  fumigatus — the  fungus,  as  a  rule,  finding  entrance  througii  a 
corneal  abrasion  from  injury.  The  ulcer  has  a  dry  appearance  and  has 
been  compared  to  a  grease-spot;  it  is  surroundeil  hy  a  gray  or  yellow 
line,  and  the  enclosed  area  ultinialely  exfoliates.  Hypopyon  and  iritis 
may  be  jjresent ;  sometimes  the  lesions  assume  the  form  of  a  simple  cor- 
neal infiltration  reseml)ling  fascicular  keratitis.  lOUett  has  reported  a 
corneal  ulc(»r  in  which  he  found  Aspergillus  nigriains.  According  to 
Morax,  my<^otic  corneal  alTections  may  be  ihie  to  tiie  \'trlicilliuni 
graphii. 

'i'lie  various  niicid-oiganisiiis  eonie  from  the  ('oiijuiitt  i\  a,  the  cili.-iiv 


ULCERS    OF    THE    CORNEA  267 

borders,  the  nares,  the  lacrimal  passages  and  from  external  contami- 
nated surroundings.  An  abrasion  of  the  cornea  from  a  chip  of  stone, 
a  fragment  of  iron  or  steel,  a  chestnut-bur,  beard  of  wheat,  or  the  like 
may  become  infected,  and  be  the  starting-point  of  these  dangerous 
forms  of  corneal  ulceration.  Typical  serpent  ulcer  is  rare  in  children, 
whose  corneas  appear  to  withstand  pneumococcal  infection. 

6.  Abscess  of  the  cornea  consists  of  a  purulent  infiltration  in  the 
deeper  layers  of  this  membrane,  over  the  center  of  which,  in  the  early 
stages,  the  epithelium  is  unbroken  and  prominent,  but  later,  discolored 
and  slightly  sunken. 

The  corneal  zone  immediately  surrounding  it  is  hazy.  The  margins 
of  the  collection  are  thicker  and  more  prominent  than  its  middle;  pus 
is  seen  in  the  anterior  chamber;  the  aqueous  humor  is  turbid  and  the  iris 
inflamed. 

Generally  the  lesion  grows  more  yellow,  notches  laterally,  bulges 
forward,  and  finally  bursts,  leaving  a  more  or  less  ragged  ulcer  covered 
with  tenacious  pus,  and  pursuing  a  course  similar  to  or  identical  with 
that  described  under  sloughing  or  infected  ulcer,  of  which,  indeed, 
abscess  is  the  first  stage.  The  causes  are  identical  with  those  described 
in  connection  with  infected  ulcer;  occasionally  a  definite  cause*  cannot 
be  ascertained. 

7.  Infected  Marginal  Ulcer. — According  to  Zur  Nedden,  this  form 
of  corneal  disease  consists  of  a  1  to  2  mm.  long  oval  ulcer,  running 
parallel  to  the  limbus,  with  only  a  slight  diffuse  infiltration  in  its 
vicinity,  the  rest  of  the  cornea  being  normal.  Sometimes  several 
superficial  infiltrations  develop,  which  may  unite  with  the  original 
ulcer  and  foi*m  a  sickle-shaped  lesion;  exceptionally  the  cornea  is 
completely  surrounded.  In  other  cases  the  multiple  infiltrations  do 
not  coalesce.  The  infection  is  believed  to  be  due  to  a  specific  micro- 
organism, to  which  Zur  Nedden  gives  the  name  "bacillus  of  infected 
marginal  ulcer."     The  prognosis  is  good;  hypopyon  rarely  forms. 

Other  types  of  marginal  ulcer  of  the  cornea  are  encountered  to  some  of 
which  reference  has  been  made,  for  example  in  association  with  catarrhal, 
diplobacillary  and  acute  contagious  conjunctivitis.  INIarginal  ulcers 
may  arise  as  a  complication  of  influenza.  In  a  number  of  them, 
observed  by  the  author,  they  began  as  grooved  lesions  just  within 
the  limbus,  became  turbid  and  spread  laterally.  In  two  of  them  the 
severity  of  the  process  was  so  great  that  they  resembled  rodent  idcers. 
Influenza  bacilli  were  not  found,  but  either  a  pneumoccocus  or  a  mixed 
infection. 

8.  Exanthematous  Keratitis. — Most  violent  forms  of  suppurative 
keratitis  occur  during  the  convalescent  stages  of  small-pox,  though 
pustules  rarely  form  upon  the  cornea.  Abscess  of  the  cornea  occasion- 
ally accompanies  scarlet  fever,  influenza,  measles,  typhoid  fever, 
typhus  fever,  and  pyemia,  and  in  these  cases  has  been  regarded  as 
metastatic,  the  pathogenic  material  having  been  conveyed  through  the 
blood,  and  not  as  coming  from  without,  as  in  the  more  usual  examples. 
Schirmer's  investigations  indicate,  however,  that  the  so-called  variolar 


268 


DISEASES    OF   THE    CORNEA 


abscess  of  the  cornea,  which  has  hitherto  been  considered  an  endogenous 
infection,  arises  by  penetration  of  the  virus  from  without. 

9.  Ulcus  rodens  is  the  name  which  was  applied  by  Mooren  to  a 
creeping  ulcer  whicii  begins  usually  at  the  upper  edge  of  the  cornea 
as  a  superficial  lesion,  separated  from  the  healthy  portion  by  a  gray, 
opaque  rim,  which  is  undermined.  The  deeply  undermined  conjunc- 
tival edge  of  the  ulcer  is  a  striking  feature  of  the  disease.  The  extent 
of  the  undermining  may  reach  4  to  5  mm.  from  the  border  of  the  cornea. 
Mooron's    ulcer   may    be    associated    with    an    ulcer    of   the    sclera 

(Parsons).  Although  vessels 
may  pass  to  a  rodent  ulcer  and 
cicatrization  apparently  begin, 
it  relapses  quickly  and  pro- 
gresses forward,  until  the  whole 
cornea  has  been  traversed  and 
sight  is  destroyed.  The  cornea 
is  not  usually  perforated  in  this 
disease,  which  is  a  rare  form, 
sometimes  bilateral,  attacking 
adult  and  depressed  subjects. 
The  process  may  last  from  two 
to  ten  months  and  even  longer. 
It  is  called  by  Nettleship  chronic 
seiyigincits  ulcer  and  Mooren' s 
nicer.  The  cause  of  the  dis<'ase 
has  not  been  discovered. 

The  prognosis  is  most  un- 
favorable (see  also  page  273)  in 
typical  cases,  but  so-called 
abortive  cases  have  been  described,  attributed  to  a  neuropathic  origin, 
in  which  the  results  of  treatment  are  more  satisfactory  than  in  the 
ordinary  types  of  this  disease. 

Fuchs  has  described  keratitis  rnarginalis  superficialis,  that  is.  a 
supf'rficial  variety  of  ulceration,  which  he  has  encountered  in  middle- 
aged  persons,  and  which  proceeds  somewhat  unevenly  from  the  corneal 
border,  so  that  the  margin  is  indented  toward  the  corneal  center  and 
framed  in  a  gray  line.  The  conjunctiva  may  be  attached  to  it  in  the 
form  <^f  a  pscudoptciygium.  The  h^sion  diffeis  from  ulcus  rod(Mis 
because  it  is  more  superficial  and  less  undermined.  It  may  last  for 
long  periods  of  time  and  is  subject  to  relapse.  Ulcers  in  this  situation 
in  old  people,  tiic  subjects  of  the  uratic  diatheses,  may  be  (juite  small 
and  may  (piickly  appear,  disappear  and  reappear.  Treat nieiit  along 
general  lines  is  often  of  marked  service. 

10.  Circular  ulcer  (marginal  ring  ula'r,  annular  ulcer)  occurs  in  the 
form  of  a  de<p  grooxe  at  the  corneal  margin,  which  gradually  progresses 
until  it  may  (-ntirely  girdle  the  cornea  and  cut  it  o ft  from  its  nutrition. 
Photophobia,  injection,  laciiiuation,  and  other  irritative  symi)tonjs 
art^   not    prominent,   but    pi'rforation   of   the   cornea  and   prolapse  of 


Flo.  V2'.i. — Moorens  uU-er  (from  a  patient  iu 
the  University  Hospital). 


II 


ULCERS    OF   THE    CORNEA  269 

the  iris  are  common.  The  disease  is  seen  in  debihtated  subjects. 
In  the  author's  service  in  the  Philadelphia  General  Hospital  with  its 
large  contingent  of  enfeebled  patients  this  type  of  ulcer  was  not  in- 
frequently encountered.  In  some  cases,  in  addition  to  the  ordinary 
local  measures,  covering  the  lesion  with  a  conjunctival  flap  appeared 
to  be  of  service. 

Another  variety  of  ring  ulcer  is  formed  as  the  result  of  a  marginal 
phlyctenular  keratitis  (see  page  260),  probably  by  the  coalescence  of  a 
number  of  small  foci.  Ring  ulcers  are  also  seen  in  catarrhal  and  puru- 
lent conjunctivitis,  and  in  the  latter  condition  may  prove  especially 
dangerous  if  they  are  hidden  by  the  chemotic  conjunctiva. 

11.  Dendriform  ulcers  {keratitis  dendriiica;  ulcerans  mycotica;  fur- 
row-keratitis;  keratite  ulcereuse  en  sillons  etoiles)  are  forms  of  keratitis 
which  appear  in  branch-like  ramifications,  having  a  superficial  situation, 
with  slight  knob-like  swellings  at  the  end  of  the  branches.  The  cornea 
may  be  insensitive  and  fluorescein  will  stain  not  only  the  lesions,  but  the 
cornea  exclusive  of  them  (Verhoeff).  The  inflammation  manifests 
itself  in  two  forms. 

In  one,  from  the  beginning,  the  symptoms  include  photophobia, 
lacrimation,  strong  bulbar  injection,  swelling  of  the  upper  lids,  and 
absence  of  the  epithelium  over  the  furrow-formed  ramifications — an 
implantation  of  the  process  in  the  deeper  corneal  layers. 

In  the  other  the  disease  assumes  a  subacute  or  torpid  character,  with 
practical  absence  of  severe  irritative  symptoms  and  loss  of  the  cover- 
ing epithelium — a  limitation  of  the  lesion  to  the  superficial  layer.  In 
the  first  form  the  opacity  is  confined  to  the  axis  of  the  furrows;  in  the 
second,  to  the  border.  After  healing,  the  scars  have  the  same  general 
configuration  which  was  present  during  the  stage  of  ulceration.  The 
disease  occurs  in  both  sexes,  and  occasionally  is  seen  in  children. 

The  cause  is  not  definitely  known.  The  disease  is  attributed  by  C. 
J.  Charles  to  a  terminal  nerve  lesion,  and  by  Verhoeff,  woo  classified  it 
with  neuropathic  affections  of  the  cornea,  to  disturbance  of  the  nerve- 
supply.  Many  of  the  cases  arise  from  febrile  herpes  of  the  cornea 
by  an  increase  and  coalescence  of  the  small  blebs.  Indeed,  the  separa- 
tion .of  dendritic  keratitis  in  some  of  its  manifestations  from  herpetic 
keratitis  is  largely  artificial  (page  285). 

A  keratitis  in  which  the  lesion  consists  of  a  peculiar,  narrow,  ser- 
piginous, superficial  ulcer,  with  lateral  offshoots,  like  the  skeleton  of 
veins  in  a  lanceolate  leaf,  usually  accompanied  with  photophobia  and 
lacrimation,  and  sometimes  ushered  in  with  severe  supra-orbital  neural- 
gia, has  been  attributed  to  malaria  {malarial  keratitis).  It  is  a 
form  of  dendritic  keratitis  and  has  been  well  studied  by  Kipp  and  by 
Ellett. 

12.  Exhaustion  ulcer  (keratomalacia)  may  appear  as  an  extensive 
ulceration  in  the  center  of  the  cornea,  or  as  a  ring  abscess  at  its  circum- 
ference. The  tissue  speedily  is  converted  into  a  slough,  which  drops 
out,  and  an  extensive  perforation  results. 

In  other  instances  the  sequel  is  described  as  a  species  of  atrophy  of 


270  DISEASES    OF   THE    CORNEA 

the  cornea,  which  is  converted  into  a  whitish,  flattened  plate  (Schmidt- 
Rirapler) . 

One  or  both  cornoae  ma}'  be  afifected.  and  the  usual  cause  is  exhaus- 
tion after  acute  iUness  or  after  prolonged  diarrhea  or  dysentery.  A 
similar  softening  and  sloughint;  of  the  cornea  maj'  be  the  result  of 
ophthalmia  neonatorum  (see  page  211),  or  cataract  incisions  which  have 
becomes  septic,  and  xerotic  keratitis  (see  page  282). 

13.  Tuberculous  Keratitis  (Tuberculosis  and  Tuberculous  Ulcer  of 
the  Cornea). — Tuberculous  lesions  of  the  cornea  almost  always  arise  by 
reason  of  an  extension  of  this  disease  from  the  uveal  tract,  including  the 
pectinate  ligament,  and  manifest  themselves  either  as  tuberculous 
nodules  or  as  a  di  luse  parenchymatous  keratitis  (see  also  page  287). 
Primary  tuberculous  ulceration  (Greeff)  and  tuberculous  nodes  in  the 
corneal  periphery  (Bach)  have  been  described  which  later  push  their 
way  into  the  cornea.  The  lesion  not  uncommonly  has  a  distinct  tri- 
angular form  (see  Fig.  136) .  A  variety  of  abscess  of  the  cornea,  without 
any  healing  tendencj',  which  by  some  authorities  has  been  regarded  as  a 
tuberculous  process,  has  been  observed  in  scrofulous  children. 

Prognosis  of  Ulcers  of  the  Cornea. — This  necessarily  depends  upon 
the  character  and  situation  of  the  corneal  lesion,  but  even  in  the  mildest 
forms  some  corneal  opacity  or  irregularity  of  the  corneal  epithelium  will 
remain  (see  page  278j.  If  bacteriologic  investigation  should  reveal  the 
presence  in  the  ulcerated  area  of  pneumococci  or  of  a  mixed  infection,  the 
prognosis  is  serious,  and  at  once  the  measures  described  in  paragraph 
(6),  page  272,  should  be  instituted  in  the  hope  that  the  spread  of  infec- 
tion may  be  prevented.  In  severe  forms  of  suppurative  keratitis  the 
prognosis  is  unfavorable,  although  active  treatment  is  often  followetl  by 
surprisingly  good  results;  indeed,  thanks  to  new  methods  of  treatment 
the  prognosis  is  far  better  now  than  in  former  times. 

Treatment  of  Ulcers  of  the  Cornea. — It  is  not  possible  to  lay  down 
definite  rules  for  the  treatment  of  all  forms  of  corneal  ulceration — this 
must  be  governed  by  the  exigencies  of  each  case;  but  certain  principles 
are  common  to  the  various  types. 

Acute  Stage:  Pain  and  Fhoto phobia. — ^These  should  l)e  iclieved  by 
the  plans  already  suggested  in  the  treatment  of  phlyctenular  keratitis. 
In  simple  ulcers,  atropin,  a  lotion  of  boric  acid,  and  dark  glassies  will 
usually  suffice,  and  prompt  (aire  often  follows  an  application  directly 
to  the  ulcer  of  nitrate  of  silver  (2  per  cent.)  or  tincture  of  iodin. 

Cocain  will  relieve  photophobia  temporarily,  but  its  continuous  use 
in  corneal  ulceration  is  positively  harmful.  Holo(!\ain,  on  the  other  hand, 
is  of  distinct  value,  as  was  pointed  out  by  llasket  Derby,  especially 
if  applied  directly  to  the  ulcerated  surface.  If  a  corneal  ulcer  is  ac- 
companied with  much  dread  of  ligiU,  the  methods  described  under 
phlyctenular  keratitis  may  be  employed,  Dionin  (2  to  5  per  cent.) 
is  of  marked  servi(^e. 

Wliciicv(;r  corneal  ulccr.ation  is  associated  with  conjunctivitis,  the 
inner  stiifaccs  of  the  lids  rn:iy  be  brushed  over  with  ;i  solution  of  nitrate 
of  silver,  gr.  ij    v  to  i^j  (0.  i;i  ().;i2  gni.  to  iiO  c.c.),  or  protargol  (.'>  to  20 


ULCERS    OF    THE    CORNEA  271 

per  cent.),  or  argyrol  (10  to  25  per  cent.)  may  be  freely  instilled.  The 
last-named  drug  is  not  without  danger,  as  it  may  cause  a  permanent 
brown  stain  at  the  seat  of  the  ulcer.  The  culdesac  should  be  care- 
fully cleansed  with  a  boric  acid  solution,  physiologic  salt  solution, 
a  collyrium  of  bichlorid  of  mercury  (1:8000),  or,  cyanid  of  mercury 
(1:2000),  mercurophen  (1:8000)  or  mercurochrome  (one  per  cent). 

Subacute  and  Torpid  Stage. — After  the  subsidence  of  the  acute 
symptoms,  or  where  the  ulcer  from  the  beginning  is  torpid,  local  stimu- 
lation should  be  secured  with  an  ointment  of  the  yellow  oxid  of  mer- 
cury, gr.  j  to  5j  (0.065-3.885  gm.).  Finely  powdered  calomel  dusted 
into  the  eye  is  also  of  excellent  repute.  In  like  manner  iodoform  or 
aristol,  in  salve  or  powder,  may  be  tried.  Eserin  has  been  recom- 
mended instead  of  atropin  in  small  sluggish  ulcers. 

Deep  and  Sloughing  Ulcers. — It  was  a  universal  and  is  still  a  common 
practice  to  instil  a  solution  of  atropin,  because  of  its  anodyne  eSect  and 
because  it  lessens  the  liability  to  iritis.  In  the  presence  of  active  iritis 
or  iridocyclitis  the  indications  for  its  use  are  evident.  The  solution 
should  be  sterile,  as  otherwise  a  simple  ulcer  may  be  infected  and  pass 
into  a  sloughing  condition. 

In  some  cases  eserin  is  employed,  because  it  stops  the  migration  of 
white  blood-corpuscles,  or  promotes  absorption  through  dilatation  of 
the  ciliary  vessels,  or  limits  the  sloughing  process.  Furthermore, 
abnormal  intra-ocular  tension  is  lowered  by  the  action  of  the  drug. 
The  strength  of  the  solution  may  be  from  X'i  to  1  grain  (0.0162-0.065 
gm.)  to  the  ounce  (30  c.c),  the  latter  being  unnecessarily  active  in 
most  cases.  One  or  two  drops  of  the  eserin  solution  should  be  in- 
stilled from  three  to  six  times  daily;  and  as,  under  its  influence,  con- 
gestion of  the  ciliary  body  and  iris  may  ensue,  as  well  as  brow-pain, 
these  complications  should  be  counteracted  by  using  a  few  drops  of 
the  atropin  lotion  at  night.  Deep  ulcers  near  the  margin  are  those 
most  suited  for  the  eserin  treatment.  The  author,  after  considerable 
experience,  is  persuaded  that  eserin  in  corneal  ulceration  has  a  com- 
paratively limited  value,  and  that  atropin  is  usually  the  better  drug^ 

During  the  progress  of  deep  and  serpiginous  ulcers  of  the  cornea  a 
careful  watch  for  rise  of  intra-ocular  tension  must  be  kept  and  should  it 
develop,  mydriatic  drugs  should  be  discontinued;  a  myotic  may  be 
required  or  paracentesis  of  the  anterior  chamber.  In  certain  deep 
ulcers  situated  at  the  margin  of  the  cornea  rise  of  intra-ocular 
tension  and  secondary  glaucoma  may  readily  become  manifest. 
Atropin,  eserin,  or  pilocarpin  may  be  used  in  conjunction  with  dionin, 
if  this  drug  is  indicated,  to  produce  an  analgesic  or  lymphagogue 
action. 

Pain  is  relieved  and  the  process  of  repair  encouraged  by  the  fre- 
quent application  of  hot  compresses  (see  page  214),  and  by  the  use  of 
dionin,  which  may  be  employed  in  solution  or  as  an  ointment.  Hot 
water  (150°  F.)  dropped  directly  upon  the  ulcer  is  recommended  by 
Lippincott.  The  culdesac  and  lacrimal  passages  should  be  irrigated 
frequently  with  antiseptic  collyria — a  saturated  solution  of  boric  acid, 


272 


DISEASES    OF   THE    CORNEA 


bichlorid    of    nicrcuiy    (1:10,000),  iKjua  chkjiini,  cyanid  of  nicrfury 
( 1 :  2000)  or  mercurophen  ( 1 :  8000.) 

1.  Impending  Perforation. — When  a  perforation  of  the  cornea  is 
Hable  to  occur  by  extension  of  the  ulcer,  a  dry  antiseptic  compressing 
bandage  should  be  applied,  removed  when  the  necessary  local  apjilica- 
tions  are  made,  and  again  applied.  Long-continued  use  of  the 
bandage  may  be  followed  by  eczema  of  the  lids.  This  should  be 
treated  by  dusting  the  parts  with  calomel  or  nosophen.  Catarrh  of  the 
conjunctiva  and  dacryocystitis  contraindicate  the  use  of  the  bandage 
unless  the  danger  of  perforation  is  imminent.  If  dacryocystitis  persists 
in  spite  of  ordinary  treatment,  the  lacrimal  sac  should  be  excised  (see 
page  758). 

If  bulging  forward  of  the  floor  of  the  ulcer  indicates  that  jierforation 
threatens,  the  intra-ocular  tension  should  be  lessened  by  paracentesis 
of  the  cornea.  This  operation  is  described  on  page  689.  It  may  be 
necessary  to  repeat  the  operation  on  several  days.  Intense  pain  will 
often  be  thus  speedily  relieved  and  healing  rapidly  result. 

2.  The  Spread  of  Local  Infection. — If,  in  spite  of  such  treatment,  the 
corneal  ulcer  continues  to  spread,  either  in  the  form  of  a  lesion  creeping 
across  the  face  of  the  cornea  or  by  passing  inward  through  its  layers, 
the  process  must  be  stopped  by  one  of  several  means :  (1)  Scraping  with 
a  curet;  (2)  the  direct  application  of  a  suitable  chemical  which  cominnes 
the  properties  of  a  germicide  and  a  caustic;  (3)  thermotherapy ;  (4)  the 
actual  cautery. 

(a)  The  ulcer  may  be  curetted  with  a  sharp  spoon  (under  a  boric 
acid  spray — de  Wecker),  all  the  sloughed  material  removed,  the  edges 
penciled  with  a  sublimate  solution  (1  :  2000),  iodofttrm  dusted  upon  its 
surface,  and  a  dry  sterile  bandage  applied.  jMules  advised  softened 
iodoform  wafers. 

(6)  The  chemical  substances  commonly  employed  are  nitrate  of 
silver,  carl)olic  acid,  nitric  acid,  trichloiacetic  acid,  tincture  of  iodin, 
and  formaldehyd.  The  first,  in  the  strength  of  10  to  20  grains  (O.lio- 
1.3  gm.)  to  the  ounce  (30  c.c),  is  applied  chrectly  to  the  seat  of  ulcera- 
tion (care  being  taken  to  avoid  the  surrounding  cornea)  by  means  of 
a  probe  on  which  has  been  twisted  a  thin  band  of  absorbent  cotton,  or 
tiie  point  of  a  pencil  of  lunar  caustic  may  be  gently  pressml  against  the 
sloughing  tissue.  Carbolic  acid  (h(|ui(l)  may  Ix'  employed  in  the  same 
manner  as  th(>  silver  solution;  or  tincture  of  iodin,  or  a  caustic  solution 
of  formaldehyd  (1  :  50),  or  trichloracetic  or  nitric  acid.  Of  tiiese 
sul)stances,  carbolic  and  trichloracetic  acid  have  given  the  autlidi-  the 
greatest  satisfaction.  Absolute^  alcohol  applied  direetly  to  the  ule<'r- 
ated  surface  is  sometimes  of  gicat  value.  It  slmuld  be  used  carefully 
and  not  too  fretjuently,  as  it  may  produce  bullous  keratitis  (Swanzy  and 
Werner).  'I'liis  eomijlication  the  author  has  ncAcr  observed  and  lie 
has  used  alcoliol  fre(]uently  as  an  M|>plicatioM  to  ulcers  of  the  ectrnea. 
Prior  to  the  application  of  these  caustics  the  ulceiated  area  should  be 
stained  with  a  solution  of  thioresceiu  (see  page  !"){)).  In  place  of 
iftdiri,  coiicciil  rated  Liigol's  solnt  ion  (iodin  2.'),  |)otassiuiii  iodid  .")().  wali'r 


ULCERS    OF    THE    CORNEA  273 

100)  is  recommended  by  Verhoeff  in  the  treatment  of  hypopyon- 
keratitis.  Prior  to  the  apphcation  crucial  incisions  are  made  in  the 
ulcerated  area,  followed  by  gentle  curetting. 

(c)  The  actual  cautery  may  be  either  a  small  Paquelin  or  galvano- 
cautery;  when  neither  of  these  is  at  hand,  a  knitting-needle  or  platinum 
probe,  heated  red  hot  in  the  flame  of  a  Bunsen  burner,  will  suffice. 
The  edge  and  floor  of  the  ulcer  should  be  gently  but  thoroughly  burned. 
Usually  one  cauterization  is  sufficient,  but  in  the  event  of  failure  to 
destroy  all  the  infected  material,  the  operation  should  be  repeated  on 
the  following  day  (see  also  page  690).  Cocain  or  holocain  render  the 
operation  painless,  but  there  is  no  objection  to  general  anesthesia  in 
nervous  patients. 

If  the  surgeon  is  careful  to  touch  only  those  portions  involved  in  the 
ulcerated  process,  it  is  said  the  resulting  scar  will  not  be  greater  than 
would  have  been  the  case  had  the  ulcer  secured  cicatrization  without 
such  treatment.  Fluorescein  will  show  the  extent  of  the  ulcer  and 
mark  out  the  area  to  be  cauterized. 

The  actual  cautery  may  be  used  to  check  the  advance  of  sloughing 
ulcers,  although  recent  improvements  in  ocular  therapeutics  have 
rendered  the  use  of  this  agent  less  frequently  necessary  than  in  former 
times.  In  rodent  ulcer  (to  which  it  should  be  applied  early  and  thor- 
oughly) it  is  one  of  the  few  means  according  to  Fuchs  that  is  efficacious, 
and  it  is  also  indicated  in  cases  of  fascicular  keratitis.  Swanzy  and 
Werner  highly  recommend  the  application  of  absolute  alcohol  in 
Mooren's  ulcer  and  record  cures  as  the  result  of  its  influence. 

Abscess  and  Hypopyon. — The  pus  should  be  evacuated.  If  the  ab- 
scess is  unbroken,  its  anterior  wall  may  be  incised  with  a  delicate  knife, 
and  the  subsequent  treatment  conducted  on  the  principles  laid  down 
for  sloughing  ulcers.  If  there  is  hypopyon,  paracentesis  of  the  cornea 
or  the  Guthrie-Saemisch  section  (see  page  690)  may  be  practised. 
Subsequenth'  iodoform  may  be  dusted  upon  the  cornea  and  a  bandage 
applied,  to  be  renewed  at  suitable  intervals. 

The  antiseptic  and  specific  treatment  of  ulcers  have  to  a  great 
degree  replaced  the  operation  of  Guthrie-Saemisch,  and  in  many 
instances  absorption  of  the  products  of  a  hypopyon-keratitis  will  follow 
the  non-operative  measures. 

Perforation. — If  perforation  of  the  cornea  and  prolapse  of  the  iris 
occur,  the  vigorous  use  of  atropin  or  eserin,  according  as  the  lesion  has  a 
central  or  peripheral  situation,  a  compressing  bandage,  and  rest  in  the 
recumbent  posture  represent  measures  which  are  sometimes  followed 
by  success.  The  advice  sometimes  given,  that  in  these  circumstances 
an  efiopt  to  replace  the  prolapsed  iris  with  a  probe  should  be  made  is 
not  wise  nor  is  the  method  feasible. 

If  the  prolapse  is  a  large  one,  the  iris  may  be  drawn  forward  through 
the  aperture  and  excised  close  to  the  cornea.  After  excision  the  aper- 
ture may  be  covered  with  a  conjunctival  flap  taken  from  the  bulbar 
conjunctiva,  twice  as  large  as  the  original  opening,  into  which  it  is 
gently  inserted  with  a  probe.     A  firm  compressing  bandage,  not  to  be 

18 


274  DISEASES    OF    THE    CORNEA 

disturbed  for  three  days,  is  applied.  This  is  the  method  of  Gamo 
Pinto.  Conjunctival  flaps,  formed  according  to  the  technic  of  Kuhnt, 
are  more  useful  under  these  conditions  than  the  Gamo  Pinto  operation. 
They  are  also  useful  in  cases  of  rapidly  advancing  ulcer  (see  page  682). 
If  the  prolapse  has  been  large,  a  more  or  less  complete  staphyloma  is 
apt  to  follow  in  spite  of  vigorous  bantlaging  and  the  use  of  eserin 
or  atropin.  An  early  iridectomy  may  prevent  this  catastrophe. 
In  an\'  event  it  is  advisable  to  perform  this  operation  as  soon  as 
it  is  safely  possible  after  the  healing  process  of  an  exten.^ive  ulcer  has 
begun. 

Other  Methods  of  Treating  Corneal  Ulcers. — (a)  Dionin. — The  value 
of  dionin  in  the  treatment  of  corneal  ulcer  is  unquestioned  and  has  been 
referred  to.  It  would  seem  that  occasionally,  in  addition  to  its  lympha- 
gogue  and  analgesic  action,  it  has  a  positive  effect  in  stimulating  corneal 
regeneration.  Immunity  is  quickly  established,  and  therefore,  as  a 
rule,  it  should  be  used  for  three  days  and  then  discontinued  for  two  or 
three  days,  or  until  its  application  is  again  followed  by  the  dionin  reac- 
tion. The  strength  of  the  solution  may  varj'  from  1  to  10  per  cent., 
according  to  the  indications,  a  good  average  general  strength  being  5 
per  cent.  Dionin  may  be  combined  with  atropin,  eserin,  holocain,  and 
cocain,  according  to  the  indications,  but,  in  the  experience  of  the 
author,  furnishes  better  results  if  employed  in  a  separate  solution  and 
the  other  drugs,  also  in  separate  solution,  are  used  either  before  or 
after  its  application.  Occasionally  its  action  seems  to  be  enhanced 
by  the  addition  of  adrenalin,  although  adrenalin  itself  is  not  a  remedial 
agent  of  satisfaction.  Powdered  dionin  or  dionin  in  salve  may  also  be 
used.  With  its  emploj'ment  bj'  subconjunctival  injection,  as  recom- 
mended by  some  surgeons,  the  author  has  no  experience.  Its  advan- 
tageous effects  are  distinctly  enhanced  by  the  use  of  a  2  per  cent,  solu- 
tion of  holocain. 

(6)  Serum  Treatment. — Romer,  believing  that  9o  per  cent .  of  infected 
so-called  serpent  ulcers  are  caused  by  the  Frankel-Weichsell)aum 
diplococcus,  with  the  aid  of  the  chemist  Merck,  developed  a  serum 
{pneumococcus  or  antipneiunococcus  scrum)  which  he  advises  in  the 
treatment  of  this  form  of  corneal  disease.  The  serum  may  be  used 
subcutaneously  and  also  subconjunctivally,  and  may  be  instilled  into 
the  conjunctival  sac.  Rc'imcr  himself  doubts  the  value  of  the  subcon- 
junctival injections.  Subcutaneously  from  3  to  5  c.c.  of  the  serum  may 
be  emploj^ed,  and  the  results  thus  far  reported  indicate  that  occai>ion- 
ally  it  seems  to  facilitate  the  cure  of  beginning  ulcers,  but  in  large,  well- 
<l(!veloi)e(l  ulcers  it  is  ineeffctual  (Zur  Netiden).  C'oin|)lications  have 
been  rei)orte(l — for  example,  myocarilitis  and  decided  febrile  r^eaction 
are  said  to  have  followed  the  injecttions  (Zeller).  With  this  method 
of  treating  corneal  ulcers  the  author  has  had  no  expi'rience.  .Vcconl- 
ing  to  Axenfeld,  this  serum  possesses  curative  |)roperties,  but,  as  pre- 
pared at  present,  its  a<'tion  is  not  suHicieiitly  eeilain  to  allow  it  to 
noplace  otluM'  niethods.  Kecenlly  Hcinier  has  in\\ov{\W{\ autosvr other npy 
in  the  treatment  of  hy|)opyon-keralit is.     The  .-^erum  olttained  fr(tin  a 


ULCERS    OF    THE    CORNEA  275 

blister  in  the  patient's  arm  is  injected  beneath  the  conjunctiva,  the 
dose  being  1  c.c. 

The  antistreptococcus  serum  or  vaccine  has  also  been  employed  in 
streptococcal  infections,  but  apparently  it,  like  the  antipneumococcus 
serum,  should  be  regarded  as  supplementary  to  other  forms  of  treat- 
ment. Of  staphylococcus  serum-therapy  too  little  is  known  to  deter- 
mine   its    influence    on    the    eye    (Axenfeld). 

A-ntidiphtheritic  serum  has  been  utilized  with  success  (Darier, 
Zimmermann,  Fromaget,  Key,  the  author)  in  the  treatment  of  severe 
corneal  ulceration.  Key  points  out  that  its  advantage  over  other 
paraspecific  agents  consists  in  the  fact  that  it  is  readily  obtained, 
that  its  dosage  is  more  certain  and  the  preparation  more  dependable. 
The  author  has  usually  employed  a  dose  of  1500  to  2000  units  every 
other  day  for  three  days.  His  results  have  been  remarkably  good. 
Deutschmann's  serum  is  a  satisfactory  agent  (yeast  serum  in  the  dose  of 
3>^  to  1 J-^  c.c.  in  children,  and  4  to  8  c.c.  in  adults) ,  according  to  reports  by 
Deutschmann,  von  Hippel,  and  others.  In  Axenfeld 's  clinic  its  effects 
were  negative.  Bacterins  prepared  from  the  micro-organisms  re- 
sponsible for  corneal  ulceration  have  proved  to  be  of  value  in  the  treat- 
ment of  infected  ulcer  of  the  cornea.  Such  bacterins  (or  vaccines) 
have  been  prepared  for  the  author  by  Dr.  B.  A.  Thomas  from  patients 
in  the  University  Hospital.  The  dose  has  varied  from  50,000,000  to 
300,000,000.  They  acted  favorably,  but  not  more  favorably  than 
antidiphtheritic  serum. 

Hypopyon-keratitis  has  also  been  treated  by  means  of  applications 
of  pyocyanase,  prepared  from  cultures  of  the  pyocyaneus  bacillus. 

(c)  Subconjunctival  Injections. — Naturallj^,  subconjunctival  injec- 
tions, so  satisfactory  in  certain  diseases  of  the  eye,  have  been  tried  in 
corneal  ulcers.  At  one  time  bichlorid  of  mercury  was  chiefly  employed, 
but,  largely  owing  to  Mellinger's  investigations,  this  gave  place  to 
physiologic  salt  solution,  which  seemed  to  act  equally  well.  There  is  a 
certain  amount  of  evidence,  however,  that  in  infected  corneal  ulcers 
cyanid  of  mercury  is  the  better  agent.  Of  this  drug,  10  to  20  minims 
(0.6—1.25  c.c.)  of  a  1  :  4000  solution  may  be  injected  beneath  the  con- 
junctiva; its  use,  in  these  circumstances,  is  strongly  urged  by  Col. 
Henry  Smith.  There  is  no  objection,  but,  on  the  whole,  rather  ad- 
vantage in  adding  chlorid  of  sodium  to  the  solution.  Of  the  bichlorid 
of  mercury  solution,  Dufour  has  recommended  injections  of  1  :  2000 
if  the  ulceration  is  active,  and  1  :  3000  to  1  :  10,000  if  the  infection  is  not 
very  robust.  Acoin  added  to  the  solutions  employed  in  subconjuncti- 
val injections  is  said  to  diminish  the  pain.  It  should  be  used  in  a  1  per 
cent,  solution,  one-third  of  which  is  added  to  two-thirds  of  the  solution 
employed. 

(d)  Since  Weekers'  advocacy  of  therrnotherapy  in  the  treatment 
of  corneal  ulcer  this  admirable  method  has  been  much  employed. 
In  this  country  Prince  was  the  first  to  call  attention  to  the  great 
value  of  chauffage  without  cauterization  in  this  regard — Pasteuriza- 
tion as  he  termed  it — whereby  the  ulcer  is  sterilized  by  means  of 
heat,   and   to  develop  a  satisfactory  technic.     The  platinum  blade 


276  DISEASES    OF    THE    CORNEA 

of  a  galvanocautory  may  bo  used,  as  a  small  metal  ball  on  the  end  of  a 
rod  heated  to  about  160°  Y.  The  lids  being  separated  the  cauterj' is 
held  close  to,  and  moved  slowly  over,  the  surface  of  the  ulcer  (the  ulcer 
must  not  be  touched  by  it)  for  one  minute.  The  surface  of  the  cornea 
may  be  moistened  with  piiysiologic  salt  solution.  This  maneuver  is 
repeated  three  times.  W.  E.  Shahan^  has  designed  a  thermophore  with 
which  the  degree  of  heat  can  be  exactly  determined.  For  hypopyon- 
keratitis  this  should  be  lo8°F.-160°F.  according  to  the  character  of  the 
lesion.  The  applicator  is  brought  in  direct  contact  with  ulcer  and 
kept  there  for  one  minute.  The  good  results  are  usually  not  apparent 
until  the  second  or  third  day. 

(e)  Additional  Measures. — Reference  to  the  value  of  iodoform 
directly  dusted  upon  corneal  ulcers  has  already  been  matle.  In  its  place 
xeroform  or  nosophen  may  be  used.  Sometimes  these  remedies  are 
employed  in  the  form  of  an  ointment,  as  are  also  iodid  of  potassium, 
iodol,  and  europhen.  The  aniline  dyes,  in  the  form  of  blue  and 
yellow  pyoktanin,  at  one  time  regarded  with  favor,  in  the  .opinion  of 
the  author  arc  valueless.  lodin-vasogen  is  reconnnended  in  infiltrate'd 
and  spreadingulcersinO.Gpercent.  solution  (it  nuiy  be  applied  directly  to 
the  ulcer  with  a  cotton-tipped  probe)  and  ariol  dusted  on  the  surface  of  an 
ulcer  after  the  application  of  the  actual  cautery  is  recommended  by 
Fischer.  If  bacteriologic  examination  should  reveal  the  presence  of 
the  diplobacillus  in  the  corneal  ulcer  {diplobaciUary  ulcer),  the  prejxira- 
tions  of  zinc  should  be  used  (sulphate,  chlorid,  or  salicj'iate  in  1  to  5 
per  cent,  solution)  and  applied  directly  to  the  lesion.  Zinc  prepara- 
tions are  also  useful  in  pneumococcus  ulcer,  and  Morax  has  tried 
ral^bit's    bile    with    indifferent    success. 

In  recent  years  ethylhydrocuprei n  (optochin)  has  been  strongly  advo- 
cated in  the  treatment  of  pneumococcus  ulcers  of  the  cornea;  it  has 
also  been  used  with  advantage  in  ulcers  not  pneumococcic  in  origin 
(Holloway).  It  may  be  applied  directly  to  the  ulcer  in  a  strength  of 
from  1  to  2  per  cent,  by  means  of  a  cotton  swab  held  in  place  for  a 
minute  and  repeated  as  required,  or  used  in  a  watery  solution  every 
hour,  or  employed  in  the  form  of  an  ointment,  combined  with  atropin. 
Decided  improvement  has  been  noted  as  early  as  the  tiiiril  or  fourtli 
day,  and  even  earlier.  At  first  its  ap])lication  causes  nuich  burning 
pain,  which  may  be:  checked  with  iiolocain.  Some  rejiorts  of  its  vahie 
are  enthusiastic  (Zentmayer) ;  others  express  disappointment.  The 
preparation  should  be  fresiily  |)repared  and  it  is  i)ossil)le  that  faihu-e 
in  this  regard  may  account  for  some  of  these  disappointments.  Puru- 
lent keratitis  has  ])een  successfully  (r(>ated  by  zinc  iontophortsis;- 
the  aiiplication  of  light   or  phototherapy  lias  also  been  used..      Darier 

'The  Tliormophorfi  in  {>i)hthalmi«'  Prartic*'.  'IViiiis.  of  Ann  r.  ( )pli.  Sor.  vol.  xvi, 
1918.  TIiIh  inKlrnnii'iit  Iuim  iniiny  usi'h  ntlicr  iIkui  tim.-i-  in  tlu'  trnituinit  of 
hypopyon-k(!ni(itiH. 

■'  For  the  nu'thod  of  a])i)IyiiiK  tlii.s  reniedial  ngont,  .see  Tnupiair's  article  on 
"Tlu"  Trfatmi-nt  of  I'litiili-nl  Kr-rnlifis  hy  Zitn-  lonfopliorrsis,"  Ophtlialrnic  Rc- 
viow,  vol.  XXX,  I'.tl  1.  |(.   I 


ULCERS    OF    THE    CORNEA  277 

recommends  scarlet  red  in  the  treatment  of  infected  ulcers  (5  per  cent, 
ointment  in  an  aqueous  solution),  and  Haass  urges  pellidol  and  azodolen, 
derivatives  from  scarlet  red,  in  2  per  cent,  ointment  in  the  management 
of  corneal  lesions  with  loss  of  epithelium.  The  application  of  radium 
has  been  advocated  by  Lawson  and  ]\IcKenzie.  In  Mooreyi's  ulcer, 
H.  Lewis  Jones  has  achieved  success  by  iising  zinc  ions.  Covering  the 
ulcerated  area  with  conjunctival  flaps  has  been  tried;  the  author  has 
employed  this  method  once  with  only  temporary  success  (see  also  page 
274).  The  clinical  use  oi  joreigyi  protein  in  ej^e  infections  has  recently 
received  considerable  attention  and  the  intravenous  and  subcutaneous 
injection  of  whole  boiled  milk  has  been  tried  and,  according  to  the 
reports,  successfully  in  various  ocular  conditions,  for  instance  keratitis. 
The  author's  experience  with  this  remedial  agent  is  too  limited  to 
express  an  opinion;  in  one  case  the  method  appeared,  temporarily, 
to  afford  relief. 

(/)  Associated  Conditions. — The  treatment  of  conjunctivitis  com- 
plicating ulcer  of  the  cornea  in  nowise  differs  from  that  suited  to 
ordinary  cases.  An  ulcer  should  always  be  carefully  examined  for  the 
presence  of  a  foreign  body,  which  may  be  covered  by  a  small  slough, 
while  misplaced  cilia  are  fruitful  sources  of  corneal  irritation  and  may 
hinder  the  prompt  healing  of  ulcers.  They  should  be  removed  with 
epilating  forceps  or  destroyed  bj'  galvanopuncture. 

The  lacrimal  passages  should  be  explored  and,  if  strictured,  rendered 
patent,  while  irrigation  of  the  lacrimal  canal  with  a  4  per  cent,  solution 
of  boric  acid,  or  1:8000  solution  of  bichlorid  of  mercury,  or  a  1: 10,000 
solution  of  mercurophen,  is  of  material  aid  in  the  treatment  of  infected 
ulcers,  because  this  passage  is  commonly  the  seat  of  unhealthy  secre- 
tion.    If  the  tear-sac  contains  pus  it  should  be  excised. 

The  teeth  should  always  be  examined,  and,  if  faulty,  the  patient 
turned  over  to  a  competent  dentist.  The  frequent  relation  of  carious 
teeth  and  pyorrhea  alveolaris  to  corneal  ulceration  is  well  established, 
and  the  irritation  of  a  new  dentition  in  young  children  has  been  found 
to  be  the  cause  of  abscess  or  ulcer  of  the  cornea.  In  brief,  the  entire 
cephalic  mucous  membrane  (Harrison  Allen)  should  be  explored,  be- 
cause, in  one  of  other  of  its  component  parts,  it  may  be  the  seat  of 
disease,  which,  even  if  it  is  not  the  cause  of  the  coexisting  corneal  ulcera- 
tion, is  none  the  less  responsible  for  retardation  in  the  healing  process. 
Some  corneal  ulcers  appear  to  have  been  caused  by  disease  of  the 
accessor}^  sinuses,  especially  the  ethmoid  sinuses,  and  by  purulent 
rhinitis  and  if  the  tonsils  are  infected  they  should  be  removed. 

Constitutional  Treatment. — The  patient,  other  things  being  equal, 
should  not  be  secluded  in  a  dark  room,  but,  with  eyes  properly  pro- 
tected with  goggles,  go  out  into  the  fresh  air  every  day.  The  diet  must 
be  nutritious  and  easily  digested;  tea,  coffee,  candies,  and  pastries 
should  be  forbidden. 

If  scrofulosis  is  present,  cod-liver  oil,  lactophosphate  of  lime,  and 
iodid  of  iron  or  syrup  of  hydriodic  acid  are  indicated;  anemia  is  best 
treated  with  the  tincture  of  the  chlorid  of  iron  or  with  the  carbonate  of 


278  DISEASES    OF    THE    CORNEA 

iron;  any  suspicion  of  malaria  requires  the  use  of  quinin  and  arsenic. 
The  sj'philitic  taint,  which  may  be  present  without  being  the  cUrect 
cause  of  the  ulcer,  indicates  the  iodids,  and  mercury,  especially  in  the 
form  of  the  bichlorid.  If  ulcers  of  the  cornea  occur  in  gouty  or  so-called 
rheumatic  subjects,  citrate  of  lithium,  mineral  waters,  iodids,  colchi- 
cum,  salicylic  acid,  salol,  etc.,  are  indicated.  Thyroid  extract  has  been 
used  by  the  author  and  Veasey  in  stubborn  non-ulcerative  keratitis, 
and  this  drug  has  recently  again  been  recommended  by  Radcliffe;  it 
has  also  been  tried  in  suppurative  keratitis.  In  tuberculous  ulceration 
of  the  cornea  (see  page  270)  important  results  are  achieved  by  the 
administration  of  tuberculin  (see  page  341). 

A  vcrj^  strict  inquiry  into  the  condition  of  the  alimentary  canal 
should  never  be  forgotten.  Calomel  is  a  useful  laxative;  the  salines  and 
saline  waters  are  often  necessary. 

The  urine  should  be  carefully  examined  for  albumin  and  sugar,  and 
for  the  products  which  indicate  imperfect  assimilation.  The  influence 
of  enterogenous  auto-intoxication  must  be  eliminated.  ! 

A  ver}'  important  element  in  the  successful  management  of  cases  of  | 

sloughing  ulcers,  especially  in  subjects  of  depressed  nutrition,  is  the 
maintenance  of  proper  circulation;  strychnin  and  digitalis  are  often 
indicated.  Severe  pain  may  be  alleviated  by  opium  or  morphin  in 
suitable  cases;  the  drug  also  has  a  favorable  influence  upon  the  ulcera- 
tion.    Codein  also  serves  a  useful  purpose. 

Results  of  Corneal  Ulceration. — Opacities  more  or  less  permanent 
follow  almost  all  ulcerations  of  the  cornea.  If  the  opacity  is  slight,  it 
is  spoken  of  as  a  nebula  or  macula;  if  dense,  as  a  leukoma.  An  old  cor- 
neal macula  possesses  a  good  reflecting  surface,  which  serves  to  distin- 
guish it,  as  Haab  points  out,  from  a  recent  inflammatory  infiltration, 
which  has  a  dull  surface. 

It  is  evident  that  upon  the  position  of  the  opacity  in  the  cornea 
depends  its  influence  upon  vision.  The  more  central  it  is  or,  rathei-.  the 
more  directly  it  encroaches  upon  the  pupillary  region,  the  greater  will 
be  the  disturbance  of  direct  vision.  Inequalities  in  the  curvatmc  of 
the  cornea  distort  the  retinal  images  and  are  fruitful  sources  of  irregular 
astigmatism. 

Wh(,'r(!  perforation  has  followed  ulceration  and  the  iris  has  re- 
maincjd  entangled  in  the  aperture,  the  attachment  is  called  an  anterior 
synechia;  the  corneal  scar  to  which  the  iris  is  fastened  receives  the  name 
adherent  leukoma  (Fig.  124).  An  eye  thus  afflictcnl  may  beconu"  (juiet 
and  retain,  either  with  or  without  opeiative  interference,  useful  visit>n; 
but  may  also  be  subject  tt)  recurring  attacks  of  inflanunation,  and  nmy 
originate  sympathetic  irritation  or  inflanuuMlioii  in  tlic  fellow  eye.  It 
may  also  become  the  subject  of  glaucoma. 

The  distention  of  a  cicatrix,  to  whose  inner  suiface  the  iris  is  at- 
tached, constituU'S  a  corneal  .staphyloma,  which  is  callcil  /()/<//  if  the  en- 
tire cornea  is  involved,  partial  if  only  a  portion  is  included,  .itid 
racemose  if  perforations  have  occurred  at  various  jxiints. 

The  mechanism  of  the  development  of  stapiiyl(»ma  is,  brielly.  as 


' 


RESULTS    OF    CORNEAL    ULCERATION 


279 


follows:  A  perforation  takes  place,  and  the  iris  falls  forward  and  at- 
taches itself  to  the  opening,  or  protrudes  through  it,  becoming  fixed 
there  by  the  lymph  thrown  out  in  the  process  of  repair.  The  scar  tis- 
sue which  remains  fails  to  withstand  the  intra-ocular  tension,  and  that 


Fig.   124. — Adherent  leukoma  (from  a  patient  in  the   Philadelphia    General    Hospital) 

portion  of  the  cornea  is  pushed  forward  beyond  its  normal  limits,  form- 
ing a  pouch-like  deformity. 

The  protrusion  may  flatten  down,  and  under  the  influence  of  fresh 
inflammation  bulge  forward  again,  or  maj' extend  between  the  palpebral 


Fig.   125. — Beginning  staphyloma  following  an  infected  ulcer  which  has  perforated  the 

cornea. 

fissures  and  prevent  the  lids  from  closing  (consult  Fig.  126).  Staphy- 
lomas, the  result  of  ulceration,  are  more  or  less  opaque,  because  they 
represent  the  scar  tissue  which  has  formed  after  the  rupture  of  the 
membrane.  Corneal  staphylomas,  which  are  not  opaque  and  have  not 
formed  under  the  influence  of  an  inflammation,  also  occur,  and  will 


280 


STAPHYLOMA    UP^    THE    CORNEA 


presontly  bo  described.  Thick  corneal  scars  and  staphylomas  may 
undergo  retrofrressive  metamorpliosis  with  the  deposition  of  hyaline 
masses  and  lime  ])articles  in  them.  Purulent  ulcers  may  develop  and 
perforate  the  lesion;  they  may  even  cause  panophthalmitis  and  subse- 


FiG.     12(j. — Complete    staphyloma    of 
the  cornea. 


Fig.  127. — Section  of  au  eyeball  with  com- 
plete staphyloma  of  the  cornea. 


quent  atrophy  of  the  eyeball.     Ulcers  thus  formed  were  named  by  Arlt 

atheromatous  ulcers.     The  condition  is  also  called  scar  keratitis,   and, 

according  to  Fuchs,  is  due  to  entrance  of  bacteria  through  the  diseased 

and  feeljly  resisting  epithelium  (sec  also  page  451). 

Anterior  synechiae  and  adherent  leu- 
koma may  also  occur,  accortling  to  von 
Hippel,  from  internal  ulcer,  without  sup- 
puration of  the  anterior  corneal  layers. 
Later  the  eye  may  become  staphylomatous. 
The  involvement  of  the  cornea  in  patho- 
logic alterations  which  come  from  b(>hind 
has  been  elal)()rately  investigated  by 
I'uchs.'  .\  purulent  exudation,  for  ex- 
ample in  endophthalmitis,  comes  in  con- 
tact with  the  posterior  layer  of  the  ct)rnea 
and  creates  a  purulent  infiltration  of  that 
l)art  of  this  tissue,  tliat  if^,nuulcus  internum. 
If  after  inflammation  of  the  cornea,  with 
loss  of  its  superficial  layers,  tiie  intra-ocular 
pressure  causes  the  remaining  lamina  to 
bulge  forwai'd  into  an  opaipie  elevation, 
the  condition  is  called  krrcctasia.  'IMiis 
diHersfrom  an  ordinary  paitial  staphyloma 

because  there  has  been  no  perforation,  ami  the  iris  tissue  is  not  involv»>d 

in  the  process. 

II  all  the  layers  of  the  coinea  down  to  the  |)osterior  elastic  lamina 

are   destroyed,   and    this   protrudes   through    the   o|)eniim   in    a    small, 

'  Arciiivi'.s  f.  ()|)litli;iliii(>l()nic,  H(l.  ilj,  I'.tHi- 


Fn;.  12h.  Staphyloma  of 
cornea,  with  hypertrophy  of  the 
cic-atricial  tisHiie. 


RESULTS    OF    CORNEAL    ULCERATION  281 

translucent,  hernia-like  pouch,  surrounded  by  a  rim  of  opaque  cornea, 
it  is  known  as  a  keratocele. 

An  orifice  remaining  after  a  wound  or,  more  commonly,  because  of 
the  failure  of  an  ulcer  to  heal  is  designated  fistula  of  the  cornea.  It  may 
last  for  a  long  period  and  stubbornly  resist  efforts  at  cure.  It  has  been 
recommended  to  touch  the  mouth  of  the  fistula  with  a  point  of  lunar 
caustic,  and  even  to  pare  the  edges  and  introduce  a  corneal  suture. 
The  best  method  of  procedure  is  to  cover  the  fistula  with  a  conjunctival 
flap.  A  cicatrix  of  horny  nature  growing  from  the  cornea  has  been 
reported  by  Arnold  Lawson,  and  he  thinks  the  epithelium  covering 
cicatrices  may  not  infrequently  become  cornified. 

Treatment  of  the  Results  of  Corneal  Ulceration. — Satisfactory  re- 
sults follow  massage  of  the  cornea.  The  massage  movements  should  be 
made  in  a  circular  and  radial  manner  over  the  cornea,  through  the 
closed  lids,  after  the  introduction  of  a  small  piece  of  the  yellow  oxid  of 
mercury  salve  into  the  conjunctival  culdesac.  Some  irritation  accom- 
panies the  method,  but  may  be  allayed  by  the  occasional  use  of  a  col- 
lyrium  of  boric  acid  and  cocain.  Instead  of  yellow  oxid  of  mercury 
salve  an  ointment  of  dionin  may  be  used  or  the  two  remedies  may  be 
combined.  In  place  of  finger  massage,  vibration  massage,  introduced 
by  Maklakow,  may  be  employed.  An  Edison  electric  pen,  the  point 
being  armed  with  a  small  ivory  ball,  is  employed.  The  vibration 
rate  varies  from  200  to  several  thousand  a  minute.  Subconjunctival 
injections  of  physiologic  salt  solution  may  aid  in  the  absorption  of 
corneal  opacities  following  keratitis,  and  similar  injections  of  magne- 
sium sulphate  and  sodium  sulphate  have  been  recommended.  Thio- 
sinamin  in  3^^-grain  (0.0324  gm.)  doses  and  gradually  increased  has 
been  employed  in  the  treatment  of  opacities  of  the  cornea.  The  author 
has  tried  the  remedy  without  satisfactory  results.  Other  methods  of 
treating  corneal  scars  are  as  follows:  A  5  per  cent,  solution  of  a  mixture 
of  equal  parts  of  thiosinamin  and  antipyrin  (J.  Galezowski) ;  an  eye- 
bath  of  ammonium  chlorid,  one  to  three  teaspoonfuls  to  a  cupful  of 
boiled  water  (Pick) ;  and  injections  of  a  15  per  cent,  solution  of  fibroly- 
sin,  which  is  a  compound  of  thiosinamin  and  salicylate  of  sodium,  the 
dose  being  }^  to  2  cm. 

Alleman  revived  the  use  of  galvanism  for  the  removal  of  corneal 
scars,  and  reported  favorable  results.  A  suitably  prepared  electrode  is 
connected  with  a  battery,  the  cathode  being  applied  directly  to  the 
anesthetized  surface  of  the  cornea,  and  the  anode  to  the  soft  tissues  of 
the  cheek.  Usually  a  current  of  from  1  to  II4  milliamperes  gives  the 
best  results.  The  seance  lasts  at  the  beginning  of  the  treatment  for  one 
minute,  and  is  gradually  increased  to  three  or  four  minutes.  Great 
care  should  be  taken  not  to  produce  too  much  reaction.  Sulzer  recom- 
mended electrolysis  and  phototherapy  in  the  treatment  of  corneal 
opacities. 

Vision  may  be  improved  by  an  iridectomy  for  new  papil,  and  the 
appearance  of  the  eye  by  tattooing  the  cornea  with  India  ink  if  the 
corneal  leukoma  is  dense.     Attempts  have  been  made  at  transplanta- 


282  DISEASES    OF   THE    CORNEA 

tioti  of  rabbit's  cornea  for  the  relief  of  dense  central  opacities.  Some 
recent  efforts  at  corneal  transplantation  have  met  with  encouraging;  re- 
sults, especially  if  a  circle  of  clear  cornea  can  be  removed  from  a 
freshly  enucleated  eye  and  transferred  to  the  opening  made  in  the 
leukomatous  cornea.  Von  Hippel's  trephine  is  a  useful  instrument  for 
this  operation.  Majritot,  emploj'ing  keratoplasty  and  using  very  thin 
grafts,  has  obtained  good  results  in  the  treatment  of  leukomas  after 
burns,  pterygia  and  scars  following  trachoma. 

The  effect  of  treatment  in  clearing  corneal  opacities  naturally 
varies  according  to  the  density  of  the  lesions;  that  favorable  results 
are  secured  by  the  methods  suggested  when  they  are  not  too  dense 
(nebulas)  is  unquestioned.  Although  even  a  small  corneal  scar, 
for  example,  one  remaining  after  a  needle  penetrates  the  corneal 
layers,  may  be  permanent,  corneal  opacity  arising  in  youth  or  in  early 
childhood,  for  instance  after  ophthalmia  neonatorum  often  in  the 
course  of  time  markedly  diminishes. 

Striate  clearing  of  corneal  opacities,  usually  in  elderly  persons,  the 
scars  having  been  present  since  childhood,  first  described  by  Fuchs, 
consists  in  a  metamorphosis  of  corneal  cicatrices  in  that  they  are 
divided  in  triangular  and  square  areas  by  strise,  or  a  star-shaped 
figure  is  formed  owing  to  a  radial  disposition  of  the  light  lines.  This 
condition  has  also  been  well  described  and  illustrated  by  Sydney 
Stephenson  and  Holmes  Spicer. 

The  treatment  of  staphyloma  in  the  first  place  is  preventive,  and 
those  measures  already  described  in  connection  with  impending  per- 
foration of  the  cornea,  and  perforation  after  its  establishment,  are  indi- 
cated— namely,  a  compressing  bandage  and  the  use  of  cserin  or,  in  some 
circumstances,  atropin.  If,  in  spite  of  this,  the  bulging  continues, 
paracentesis  of  the  anterior  chamber  or  an  iridectomy  opposite  the 
clearest  part  of  the  cornea  may  be  performed.  Indeed,  an  iridectomy 
to  prevent  the  formation  of  staphyloma  is  often  useful  while  the  cor- 
neal scar  is  still  flat,  especially  if  the  tonometer  indicates  any  rise  of 
tension  (see  also  page  271).  If  the  tlisease  has  been  so  extensive  tiiat  a 
complete  and  unsightly  staphyloma  has  formetl,  which  is  tiie  seat  of 
pain  and  a  source  of  danger  to  the  fellow  eye,  excision  of  the  globe  is 
indicated,  or  one  of  the  various  substitutes  for  the  operation  of  enu- 
cleation (see  page  713). 

In  addition  to  the  various  types  of  coiiieal  uhci  wliich  havf  been 
described  in  the  preceding  {)aragraplis  there  remain  other  types  of 
ulc(!rative  keratitis  more  satisfactorily  discussed  in  separate  scM'tions 
as  follows: 

Keratomalacia  (Xerotic  Keratitis — a  name  also  appli(Hi  (o  kera- 
titis (\  iagophthiiliiio  — iVcrro.s/.s  Corneiv;  Infantile  I'lceration  of  the 
(Cornea,  with  Xerosis  of  the  Conjunctiva) . — This  disease  is  characterized 
by  dryness  of  the  conjunctiva  and  destructive  ulceration  of  the  cornea, 
and  usually  ai){)ears  in  infants  during  ti\(*  first  year  of  life.  Accoiding 
to  Stcpiicnsoii  it  is  cspcci.Mlly  liable  to  arise  about  (he  eiglitli  month,  but 
may  develop  from  the  third  to  the  twentieth  montlis. 


NEUROPAEALYTIC    KERATITIS  283 

Cause. — It  occurs  only  in  anemic,  badly  nourished  individuals. 
It  has  been  seen  accompanjdng  meningitis,  measles,  and  variola,  and 
among  children  with  diarrhea,  enteritis,  tuberculosis,  S3'philis,  and 
those  who  are  inmates  of  homes  whose  surroundings  are  unhygienic. 
Bloch  thinks  a  deficiency  of  fat  in  the  food  is  responsible  for  many 
cases  of  infantile  ulceration  of  the  cornea.  Bacilli  have  been  found, 
but  the  special  microbe,  if  it  exists,  has  not  been  certainly  isolated. 
In  a  few  cases  the  Spirochseta  pallida  has  been  found  (Stephenson). 
The  disease  is  not  a  common  one.  A  somewhat  similar  condition  has 
been  described  in  the  eyes  of  negro  children  in  the  South  (Kollock). 

Symptoms. — In  the  beginning  there  are  conjunctival  congestion 
and  lacrimation,  but  the  peculiarity  of  the  disorder  is  the  development 
of  the  appearances  described  under  Epithelial  Xerosis  (see  page  247), 
in  connection  with  the  corneal  lesions.  A  gray  haze,  rapidly  turning 
into  ulceration,  appears  in  the  cornea,  followed  by  inflammation  of  the 
iris  and  the  formation  of  hj^popj^on.  Perforation  of  the  cornea  and 
destruction  of  the  eyeball  ma}'  result.  Both  ej-es,  as  a  rule,  are 
affected,  one  earlier  than  the  other. 

The  prognosis  is  very  unfavorable;  the  patients  usually  die  (accord- 
ing to  Stephenson  the  disease  is  fatal  in  50  per  cent,  of  the  cases)  of  the 
wasting  disease  which  has  occasioned  the  trouble,  or  of  an  intercurrent 
pneumonia.  In  some  cases  streptococci  have  been  found  in  the  local 
lesions,  and  foci  of  these  micrococci  scattered  throughout  the  body. 

Treatment. — This  resolves  itself,  besides  the  ordinary  treatment 
of  severe  corneal  ulceration,  into  the  administration  of  the  internal 
remedies  which  are  indicated  by  the  general  state  of  the  patient. 
Bloch  recommends  the  administration  of  cod-liver  oil,  and  feeding 
the  child  with  breast  milk  or  whole  sweet  milk. 

Neuroparalytic  keratitis  is  the  name  applied  to  an  ulceration  of 
the  cornea  which  arises  because  of  paralysis  of  the  trigeminus. 

Causes. — Disease  or  lesion  of  the  Gasserian  ganglion  or  of  its 
branches  or  of  the  nuclei  of  the  fifth  pair,  periostitis  of  the  orbit, 
syphilitic  deposits,  and  fracture  of  the  skull  may  cause  the  a6ection. 
It  frequently  arises  after  removal  of  the  Gasserian  ganglion  for  the 
relief  of  trifacial  neuralgia,  or  division  of  the  sensory  root  for  the  same 
purpose  or  the  injection  of  alcohol  into  the  ganglion  or  its  branches. 
This  keratitis,  due  to  alcohol  injections,  may  appear  in  a  day  or  two 
or  be  delayed  for  a  long  period  of  time — a  year  or  more. 

The  corneal  lesion  has  been  ascribed  to  a  trophic  change;  to  the  less- 
ened power  of  resistance  which  the  cornea  in  its  insensitive  condition 
presents  to  external  injuries;  to  the  irritation  of  the  fifth  nerve  by  the 
lesion;  to  micro-organisms;  and  to  increased  evaporation  from  the  sur- 
face of  the  cornea. 

Wilbrand  and  Saenger  dismiss  the  traumatic  theory  and  believe 
that  some  trigeminal  fibers  from  the  first  branch  remain  and  carry  the 
irritation,  which  is  finally  concerned  with  the  development  of  the  dis- 
ease. Such  irritations,  according  to  Verhoeff,  might  readily  cause  an 
acid  reaction  and,  if  sufficiently  long  continued,  originate  the  lesions. 


284  DISEASES    OF   THE    CORNEA 

Hence,  in  the  language  of  Parsons,  the  disease  is  probably  due  to  irrita- 
tive chang(^s  in  and  al)out  the  degenerating  nerve. 

Symptoms. — The  keratitis  preceded  by  slight  dulness  or  cloudi- 
ness of  the  cornea  begins  in  its  center  with  a  depression  or  ex- 
foliation of  the  epithelium,  and  spreads  peripherally  until  the  central 
necrosis  or  slough  separates,  and  perforation  of  the  cornea  with  pro- 
lapse of  the  iris  occurs.  The  anterior  chanil)er  may  contain  pus  or  pus 
mixed  with  blood.  Beyond  and  around  the  central  lesion  the  cor- 
neal tissue  is  comparatively  clear,  especially  in  a  margin  of  2  to  3  mm. 
in  width,  but  in  the  periphery  there  may  be  secondary  foci  of  infiltra- 
tion, closely  connected  with  inflammation  of  the  neighboring  conjunc- 
tiva. The  surface  of  the  cornea  antl  conjunctiva  is  anesthetic.  The 
intra-ocular  tension  is  diminished.  Pain  and  irritation  are  never 
conspicuous  and  these  symptoms  usually  are  entirely  absent. 

The  -prognosis  in  the  absence  of  prompt  treatment  is  unfavorable, 
and  destructive  inflammation  often  results,  although  occasionally  the 
keratitis  subsides  without  the  formation  of  purulent  material.  The 
center  of  the  cornea,  however,  is  flattened  and  presents  a  dense  scar  at 
the  termination  of  the  disease. 

Treatment. — ^The  usual  treatment  of  corneal  ulcers  is  necessary, 
especially  useful  are  dionin  and  holocain.  The  affected  eye  should  be 
excluded  from  the  influence  of  external  irritants,  either  by  a  carefully 
applied  antiseptic  bandage  or  by  a  Buller's  shield,  or.  better,  by 
stitching  together  the  lids.  If  a  median  tarsorrhnphy  is  promptly 
performed  the  results  are  invariably  good;  indeed  the  elaboration  of 
the  process  is  usually  promptly  checked.  The  lids  should  not  be 
separated  for  a  long  period  of  time  (weeks,  even  months)  and  after 
their  separation  the  patient  should  wear  protecting  goggles.  The 
same  operation  is  indicated  as  a  prophylactic  measure  preceding 
operation  on  the  Gasserian  ganglion  or  its  l)ranches.  Holocain  i)er- 
sistently  used  prior  to  operation  and  the  internal  administration  of 
sulphate  of  chromium  is  said  to  be  of  ailvantage.  If  the  liils  are  not 
stitched  together  prior  to  operation,  the  eye  should  be  covered  with  a 
protec^ting  shield,  such  as  has  been  devised  by  W.  W.  Keen.  I^xperi- 
mental  evidence  intlicates  the  propriety  of  preventing  evaporation  by 
keeping  tlu;  eye  in  a  moist  atmosphere. 

Keratitis  e  Lagophthalmo  {Keratitis  of  Desiccation;  Keratitis 
Xerotica — Feuer). — This  alTcction  aris(>s  because  the  cornea  is  ex[K).sed, 
owing  to  defective  closuie  of  the  lids  (see  also  pages  100  and  101).  .As 
the  nisult.  of  this  exjjosun^  tluMv  is  desiccation  of  the  corneal  epithelium, 
which  becomes  fissuretl  and  in  places  exfoliates.  Thus,  a  path\va\  for 
mi(trobic  invasion  is  opened,  and  ulccM-ation  and  suppuration  ociur. 
The  usual  causes  of  this  affection  are:  |)r()ptosis  of  the  eyeball,  as  in  (>x- 
oplithalinic  goiter  (see  page  (ill)  and  exophthalmos  (.see  page  ().")]) ; 
paralysis  of  the  orbicularis,  as  in  facial  palsy  (.>^ee  page  101);  and  long- 
contimied  illness  associated  with  defective  closure  of  the  lids. 

The  treatment  consists  in  protectingthecorn(>a  by  asuil:il>le  b;indagc 
or  shield,  or  in  some  i-ases  by  stitching  the  lids  together  (see  page  liOl)). 


HERPETIC    KERATITIS  285 

Herpetic  Keratitis  {Herpes  of  the  Cornea).^ — The  corneal  lesions 
associated  with  herpes  zoster  ophthalmicus  have  been  described  on 
page  173.  The  present  disease  consists  of  a  vesicular  eruption  upon 
the  cornea,  which  breaks  down  and  forms  an  ulcer,  characterized  by  a 
denudation  of  epithelium  not  unlike  that  produced  by  injury. 

Causes. — Horner  described  herpes  of  the  cornea  with  whooping- 
cough,  intermittent  and  typhoid  fever,  and,  in  general  terms,  with 
those  a :  ections  in  which  herpes  of  the  lips  and  nose  is  found.  It  is  seen 
in  acute  and  subacute  disease  of  the  posterior  nares  and  pharynx,  and 
also  in  a'^ections  of  the  respiratory  apparatus  generalh'  (pneumonia, 
bronchitis),  and  may  follow  or  be  associated  with  influenza.  In  a 
number  of  instances  it  has  followed  antityphoid  inoculations.  The 
author  observed  during  the  late  war  a  number  of  cases  where  this  etiologic 
factor  was  in  evidence,  sometimes  associated  with  herpes  of  the  face. 
Lancaster  refers  to  more  than  twenty  cases  under  his  observation,  the 
primar}^  lesion  probablj^  existing  in  the  gangUa.  During  the  recent 
epidemics  of  influenza  numbers  of  corneal  affections  developed,  some 
of  them  of  the  herpetic  type,  which  have  been  classified  wdth  the  neuro- 
pathic group,  where  in  addition  to  the  corneal  ulceration  there  were 
pain  along  the  distribution  of  the  branches  of  the  trigeminus  and  anes- 
thesia of  the  cornea  (see  also  dendritic  keratitis  page  269). 


Fig.   129. — Showing  various  shapes  and  positior.s  of  herpes  ulcers  (Haab). 

Symptoms. — The  typical  disease  begins  with  the  symptoms  of 
catarrhal  conjunctivitis  followed  by  a  series  of  transparent  vesicles 
upon  the  cornea,  which  have  been  compared  to  a  string  of  small  beads. 
The  vesicles  are  placed  in  a  circle,  or  run  in  a  diagonal  or  irregular  line 
across  the  cornea.  They  speedily  rupture  and  leave  an  open  patch, 
deprived  of  epithelium,  which  is  anesthetic  and  has  irregularly  serrated 
margins,  upon  which  the  remains  of  vesicles  may  be  seen.  The  lesions 
are  easily  shown  by  fluorescein,  which  may  also  produce  a  deep  or  super- 
ficial coloration  of  those  portions  of  the  cornea  apparently  unaffected. 
The  sensation  of  the  cornea  is  diminished. 

The  progress  of  repair  is  slow^ ,  and  is  often  interrupted  by  the  reap- 
pearance of  fresh  vesicles.  The  herpetic  ulcer  may  develop  mani- 
festations of  great  severit3\  Sometimes  more  than  one  herpetic 
ulcer  appears  at  the  same  time,  the  intervening  cornea  being  practically 
unaffected.  A  common  disposition  is  a  more  or  less  central  ulcer, 
with  a  second  one  usualh'  crescentic  in  shape  near  the  periphery.  The 
disease  may  be  complicated  with  pus  in  the  anterior  chamber  and  iritis. 

1  This  term,  as  Horner  observed,  is  often  incorrectly  used  as  sj'nonymous  with 
phlyctenular  keratitis- 


280 


DISEASES    OF    THE    COKXEA 


Pain  in  the  eye  and  brow,  often  violent  photophobia,  hicriination.  and  a 
gritty  sensation  are  the  subjective  symptoms. 

Treatment. — This  consists  in  rcheving  the  general  condition;  usually 
(luinin  in  full  doses  is  indicated,  and  salicylate  of  sodium  is  a  most 
valuable  remedy.  Atropin,  holocain,  hot  compresses,  and  dark  glasses 
are  needed.  Dionin  is  of  signal  service.  After  the  formation  of  the 
ulcer  the  treatment  is  conducted  on  general  principles.  A  pressure 
bandage  is  of  advantage,  and  in  many  cases  an  application  of  tincture 
of  iodin  is  promptly  successful.  It  may  be  repeated  as  often  as  re- 
quired. Occasionally  the  application  of  carbolic  or  trichloracetic  acid, 
thermothorapy  or  even  the  actual  cautery  may  be  needed  to  subdue 
stubborn  ulcers  of  this  character. 

Rosacea  Keratitis. — Usually  in  women  at  or  about  the  fortieth 
year  of  life,  but  sometimes  at  an  earlier  period,  in  association  with  acne 
rosacea,  there  may  develop  a  form  of  keratitis.  The  manifestations 
vary.  There  may  V)e  lacrimation,  blepharospasm,  blepharitis,  bulbar 
injection,  and  the  development  of  a  grayish-white,  vascularized  corneal 
infiltration  with  small  circular  ulcers,  as  in  Holloway's  patient;  or 
small  marginal  ulcers  and  infiltrations  may  arise  (Erdmann;  see  also 
page  201).  The  treatment  of  the  coexisting  acne  rosacea  is  important. 
The  eye  lesions  are  favoral)ly  influenced  by  the  usual  lotions,  by  scopol- 
amin-mydriasis,  and  especially  by  holocain. 

Keratitis  bullosa  in  many  instances  is  a  symptom  and  not  a 
separate  disease,  inasmuch  as  it  consists  of  the  formation  of  one  or  more 
small  blebs  of  short  duration  {keratitis  vesiculosa) ,  or  of  larger  blebs  of 
more  enduring  existence  {keratitis  bullosa) ,  upon  the  cornea  of  an  eye 
the  subject  of  iridocyclitis,  interstitial  keratitis,  or  glaucoma. 

Cause. — This  affection  formerly  was  attributed  to  a  mechanical 
effect  due  to  incn^ased  intra-ocular  tension.  Probably  under  the 
pathologic  conditions  existing  an  interepithelial  edema  takes  place, 
the  fluid  penetrating  from  the  anterior  chamber  through  the  changed 
and  unresisting  endothelial  cells,  or  coming  from  the  capillary  network 
of  the  corneal  lim])us.  This  edema  causes  the  epithelial  cells  to  ile- 
generate  and  loosen  their  hold  on  Bowman's  membrane,  and  they  are 
raised  in  the  form  of  bulla?.  Sotuctinics.  in  addition  to  epithelium,  the 
walls  of  the  l)ulla)  are  composed  of  a  homogeneous  membrane.  Occa- 
sionally moderately  large  vesicles  form  upon  a  cornea  otherwise  nornuil, 
and  in  one  reported  case  malaria  was  believed  to  be  the  chief  factor  in 
their  causation. 

Symptoms.  In  addition  to  the  formation  of  tiic  l)lcl»s,  there  are 
burning  pain,  photophol)ia,  injection  of  the  bulbar  conjunctiva,  ami 
rupture  of  the  vesicles,. leaving  an  abrasion  which  may  go  on  to  ulcer;i- 
tion,  and  its  infection  may  produce  sloughing  of  the  cornea,  and  even 
panophtiialinit  is.  There  is  a  strong  tendency  to  recurrence,  and  with 
i'acli  new  foiiuation  of  vesicles  the  violent  iiillainmatory  symptoms  are 
repeated. 

Treatment.  This  consists  in  |)iinclure  of  tlie  l»iei)s  and  suital)le 
local  measures,  according  to  the  causative  disea.se.     Holocain,  dionin, 


PARENCHYMATOUS    KERATITIS  287 

and  sometimes  pilocarpin  are  useful.  In  severe  cases  iridectomy  and 
even  enucleation  may  be  needed.  The  recurrent  character  and  the 
remissions  which  have  been  described  have  suggested  the  use  of  anti- 
periodic  doses  of  quinin;  and  these  have  been  given  with  good  results. 

The  second  group  of  corneal  inflammations,  a  description  of  which 
follows,  is  the  non-ulcerative,  and  includes  a  variety  of  affections  free 
from  ulceration. 

Vascular  keratitis  is  a  superficial  vascularity  (sometimes  deep) 
and  opacity  of  the  cornea,  and  is  seen  in  pannus  caused  by  trachoma 
hds  (see  page  236),  and  in  phlyctenular  pannus  the  result  of  many 
relapses  of  phylctenular  keratitis  (see  page  261),  and  in  certain  types 
of  parenchymatous  keratitis  (page  288) ,  Such  conditions  however,  are 
also  included  in  the  general  term  vascularization  of  the  cornea,  and  do 
indicate  separate  forms  of  disease. 

A  form  of  vascular  keratitis  characterized  by  the  formation  of  two 
opposite  vascular  areas  at  the  upper  and  lower  margins  of  the  cornea, 
which  approach  each  other  until  the  vascularization  is  complete,  the 
intervening  cornea  being  hazy  or  sometimes  yellowish  resembhng  a 
purulent  infiltration,  was  described  by  Carter.  He  beheved  that  the 
disorder  was  of  neuropathic  origin  evidently  but  this  condition  should 
be  classified  with  parenchymatous  keratitis   (see  page  288). 

Parenchymatous  Keratitis  (Interstitial,  Syphilitic,  Inherited, 
Specific,  and  Diffuse  Interstitial  Keratitis;  Anterior  Uveitis). — This  is  a 
diffuse  keratitis  in  which  a  chronic  inflammation  of  the  whole  thickness 
of  the  cornea  takes  place,  until,  almost  always  without  ulceration,  but 
always  with  superficial  or  deep  vascularization,  the  cornea  in  severe 
cases  passes  into  a  condition  of  universal  thick  haziness. 

Causes. — The  majority  of  cases  of  interstitial  keratitis  are  due  to 
inherited  syphilis,  the  evidence  of  which  is  present  in  at  least  80  to  90 
per  cent,  of  them.  In  a  small  percentage  of  cases  (2  to  10  per  cent., 
according  to  Stephenson's  investigations)  acquired  si,philis  is  the 
etiologic  factor.  Next  to  syphihs,  tuberculosis  furnishes  the  largest 
contingent  of  cases  of  interstitial  keratitis  (about  10  per  cent,  it  is  usu- 
ally stated,  a  percentage  almost  certainly  higher  than  the  facts 
warrant) .  Forms  of  parenchymatous  keratitis  have  been  attributed  to 
rachitis,  malaria,  myxedema,  trypanosomiasis,  leprosy,  the  climacteric, 
and  depressed  nutrition.  Interstitial  keratitis  is  occasionally  seen  in 
animals  and  may  be  the  result  of  trauma  in  an  individual  with  heredi- 
tary syphilis. 

It  is  most  frequently  observed  between  the  ages  of  five  and  fifteen 
years  (most  frequent  between  six  and  twenty — Hoor),  occasionally 
as  early  as  the  third  year,  but  rarely  after  the  thirtieth  year.  A  few 
cases  are  on  record  as  late  as  the  sixtieth  year  of  life.  The  disease  is 
more  frequent  in  females  than  in  males,  occurring  in  the  former,  it  is 
usually  stated,  especially  at  the  periods  of  second  dentition  and  of 
puberty.  Igersheimer's  statistics,  however,  show  no  material  difference 
in  its  incidence  in  the  two  sexes. 

Parenchymatous  keratitis  appears  to  have  been  aggravated  by  the 


288 


DISEASES    OF   THE    CORNEA 


development  of  menstruation,  and  also  to  have  undergone  improve- 
ment by  establishment  of  the  menstrual  molimen.  It  is  probable  that 
the  affection  occu.sionally  arises  in  utero,  and  a  congenital  form  of 
the  disease,  not  diitering  in  appearance  from  the  ordinary  or  postnatal 
form  of  the  disease,  has  been  described  (Randolphj.  It  has  been  pro- 
duced in  animals  by  inoculation  of  the  eye  with  syphilitic  material, 
and  in  human  beings  it  has  followed  a  chancre  on  the  Hd  or  conjunctiva 
(10  cases,  according  to  J.  T.  Carpenter).  Spirochirta  paUida  have 
been  found  in  the  corneal  layers.  Fuchs  has  observed  in  some  cases 
of  interstitial  keratitis  that  in  shape  the  cornea  is  a  vertical  ellipse. 
In  general  terms  he  believes  that  an  oval  cornea  is  more  frequent  m 
persons  with  iniieritod  syphilis  and  in  those  who  are  likely  to  acquire 
interstitial  keratitis  tiiaii  it  is  in  other  patients.     It  does  not  follow, 

as  he  points  out,  that  because  the 
cornea  is  oval  the  patient  has  in- 
herited syphilis. 

Symptoms. — The  lesions  begin 
cither  in  the  center  or  at  the  margin 
of  the  cornea.  In  the  first  instance, 
after  a  few  days  of  slight  ciliary  cori- 
gestion  and  watering,  a  faint  cloudi- 
ness appears.  The  spots  of  haze,  if 
carefully  examined,  will  be  found  to 
be  interstitial  opacities,  composed  of 
round  cells — that  is,  within  the  struc- 
ture of  the  cornea  itself  anil  not  on 
either  surface. 

In  two  or  three  weeks  they  spread  until  the  whole  cornea  is  in- 
vested with  a  diffuse  haziness,  veiling  or  completely  hiding  the  n-is, 
except,  perhaps,  through  a  narrow  rim  at  the  margin  of  the  cornea. 
The  steamy  surface  has  often  been  compannl  to  ground  glass;  it  may 
have  a  yellowish  tint.  Careful  inspection  will  reveal  that  the  opacity 
is  not  uniform,  but  contains  saturated  whiter  spots  scattered  through 
it,  which  have  been  described  as  "centers  of  the  disease."  Kxanuiia- 
tion  with  the  corn(>al  microscope  demonstrates  that  the  corneal 
haze  may  be  resolved  into  very  fine  points  of  grayish  color.  Folds  in 
Dcscemet's  membrane  of  various  shapes  are  also  at  times  dis- 
coverable. There  are  always  at  this  stage  ciliary  congestion  aiul 
some  pain  and  dread  of  light.  Blood-vessels  derived  from  the  ciliary 
vessels  are  thicklv  set  in  the  layers  of  the  cornea  ami  i)roduce  a  ilull 
ivd  color  "the  salmon  patch  of  Hutchinson."  These  p:itrhes  may 
be  small  and  crescent  shaped,  or  large  and  sector-like.  In  one  type 
(ref(>rred  to  on  page  287).  the  vascularity  creeps  from  above  and  below 
until  the  entire  cornea  is  cherry  red.  If  the  disea.^e  begins  at  the 
niarnin  of  the  cornea,  areas  of  cloudiness  appear  at  dilTcrent  portions 
of  it,  and  griidually  from  all  sides  ai)proach  the  ciMiter  until  lh.>  general 
ha/i'ness  is  c.ini.lctc.  Owing  to  the  forncition  of  vess.>ls.  the  linibus 
b('-('omcs  red   and  sw-.llcn   at    tlu.sc   portions   which   correspond   to   tlie 


Fig.     130.  —  Vessel     formation    in    the 
cornea  after  interstitial  keratitis. 


PARENCHYMATOUS    KERATITIS 


289 


marginal  opacities,  giving  rise  to  an  appearance  which  has  received  the 
name  ' '  epaulet-hke  swelHng."  It  is  most  often  seen  in  the  upper  cor- 
neal margin. 

The  subjective  symptoms  of  irritability  and  photophobia  are  more 
pronounced  in  strumous  children  who  are  at  the  same  time  syphilitic. 
Ulceration  rarely  occurs,  but  none  the  less  ulcers  of  discoverable  size 


Fig. 


131. — From  a  photograph  of  a  patient  in  the  Children's  Hospital,  the  subject  of 
inherited  syphilis  and  interstitial  keratitis. 


are  sometimes  present,  and  hj-popyon  and  an  appearance  resembling 
an  accumulation  of  pus  in  the  layers  of  the  cornea  have  been  reported. 
Iritis  and  iridocyclitis  are  not  uncommon  (fulty  one  half  of  the  cases), 
in  one  form  the  iritis  being  associated  with  deposits  on  the  posterior 
layer  of  the  cornea  (keratitis  punctata,  Descemetitis)  and  the  forma- 
tion of  anterior  sj'nechise;  definite  nodes  in  the  iris  are  sometimes 

19 


290  DISEASES    OF   THE    CORNEA 

discoverable  (Igersheimer).  Severe  inflammation  of  the  ciliary  region 
is  occasionally  encountered;  secondary  glaucoma  and  shrinking  of  the 
eyeball  may  follow  (phthisis  bulbi). 

In  the  course  of  time,  varying  in  accordance  with  the  treatment, 
the  eye  begins  to  clear,  usually  from  the  periphery.  Perfect  recovery 
of  the  transparency  must  be  rare,  although  the  remaining  haze  may  be 
slight.  Years  after  an  attack  of  interstitial  keratitis  minute  vessels, 
nearly  straight,  branching  at  acute  angles  and  short  bends,  maj'  be 
detected  in  the  cornea.  These  appearances  have  been  especially  de- 
scribed by  Nettleship  and  HirschbcMg,  the  latter  observer  stating  that 
the  vessel  formation  never  subsides  entirely,  and  he  has  seen  this  con- 
dition, with  the  aid  of  a  corneal  loup,  thirteen  years  after  an  attack. 
In  Derby's  investigation  of  the  end  results  of  parenchymatous  keratitis 
in  some  cases  it  was  not  possible  to  demonstrate  the  remains  of  vessel 
formation. 

In  addition  to  the  complication  of  iritis  and  inflanniiation  of  the^ 
ciliary  body,  more  or  less  retinitis  is  very  apt  to  be  preseat,  although , 
a  pure  retinitis  is  unusual.  Disseminated  choroiditis,  and  even  opt  it- 
neuritis  and  retinal  hemorrhage,  have  also  been  observed;  indeed,  it  is 
not  uncommon  to  find,  far  forward  in  the  eye-ground,  areas  of  choroi- 
ditis {anterior  choroiditis)  not  only  in  the  diseased,  but  also  in  the  un- 
affected eye  (see  also  page  378).  Secondarj-  glaucoma  may  develop, 
with  deep  cupping  of  the  disk.  H^'drophthalmos  has  been  reported 
(E.  von  Hippel).  Periods  of  rise  of  tension  during  the  course  of  paren- 
chymatous keratitis  are  not  uncommon,  and  must  be  carefully  guarded 
against,  using  eserin  or  by  paracentesis  of  the  cornea.  It  is  important 
to  make  frequent  tonometric  examinations  during  the  coiwse  of  the 
disease.  Sometimes  the  tension  is  below  normal.  Myoina.  sometimes 
of  high  degree  and  sometimes  associated  in  t  lie  glaucomatous  cupping  of 
the  disk,  and  irregular  astigmatism  are  not  infrequent  sequels  of  paren- 
chymatous keratitis. 

Tile  subjects  of  typical  forms  of  tliis  disease  often  present  a  remark- 
able combination  of  physical  defects.  The  dwarfed  stature,  tlu>  coarse, 
flabby  skin,  the  sunken  nasal  britlge,  the  scars  at  the  angle  of  the  mouth 
and  also  of  the  nose,  the  malformed  permanent  teeth,  in  which  the 
central  incisors  hav(>  vertically  notched  (Mlg(>s  (Hutchinson's  teeth), 
indeliblv  stamp  the  inheritance  of  the  patient.  This  character  of  teeth 
is  present  in  i^etween  20  and  30  per  cent,  of  the  cases.  Indeetl,  it  has 
been  seen  as  frequently  as  31  tim(>s  in  48  cases.  The  presence  of  deaf- 
ness, cicatrices  in  the  pharynx,  chronic  periostitis  of  the  tibia,  synovitis 
of  the  knee-joint  (synnnelric  or  unilateral),  and  indurated  lymphatic 
glands  further  emphasize  the  syphilitic  taint.  Not  only  are  the  liilTi'r- 
ent  forms  of  Hutchinson's  teeth  fre<iuently  evident,  including  the  peg- 
shaped  milk  canine,  but  also  the  defect iv(>  lirst  peiiiian(>nt  molars 
describ(!d  by  ]''()urni(M-  and  Darier,  .nid  the  ''sloped  molar"  of  Giff"ord. 

The  inlcrslilial  kei'alilis  of  dciinircd  si/philis  is  usually  a  late  second- 
ar\'  or  a  Iciliary  event.  If  may  l)e  circumscribed  or  dilTuse,  and  is 
more  apl    to   be   unil;iter;d    lli:in   I  he   wiriety   due   lo   inherited  syphilis. 


PARENCHYMATOUS    KERATITIS  291 

Its  evolution  is  relatively  more  rapid,  and  it  is  more  promptly  amen- 
able to  treatment.  Usually  it  appears  in  adults  between  the  twentieth 
and  fiftieth  year  of  life;  exceptionally  it  has  been  seen  in  children  (see 
also  page  288) .  Its  development  as  the  result  of  a  Hd-chancre  has  been 
noted. 

Diagnosis. — The  course  of  the  disease  is  usually  quite,  typical, 
and  the  associated  symptoms  characteristic.  The  age  of  the  patient 
in  most  instances  helps  to  exclude  primary  glaucoma,  while  the  history 
and  character  of  the  inflammation  differentiate  it  from  old  corneal 
maculse  and  from  the  diffuse  infiltration  of  the  cornea  which  is  some- 
times seen  as  the  result  of  injury.  Wassermann's  (or  luetin)  test 
should  always  be  made,  and,  to  distinguish  between  cases  due  to 
syphilis  and  tuberculosis,  the  reaction  of  the  patient  to  tuberculin  or  to 
von  Pirquet's  test  should  be  tried. 

The  presence  of  the  minute  straight  vessels  is  good  evidence  of 
former  parench3-matous  keratitis.  These  vessels  must  be  distinguished 
from  those  which  remain  after  pannus  from  trachoma.  According 
to  Hirschberg,  in  the  latter  condition  they  are  more  superficial  and  pass 
into  anterior  conjunctival  vessels.  There  are  well-formed  anastomo- 
ses, the  broader  veins  are  accompanied  by  finer  arteries,  and  there  are 
pecuKar  ramifications  of  the  small  deep  vessels.  The  vessels  seen  in 
corneal  scars  after  ulceration  are  confined  to  these  cicatrices.  The  resjb 
of  the  cornea  is  free. 

Certain  atypical  cases  of  interstitial  keratitis  have  been  described, 
namely,  forms  in  which  the  opacities  are  stripe-like;  others  in  which 
they  are  ring-like;  others  presenting  the  appearance  of  pus  in  the  layers 
of  the  cornea,  the  so-called  abscess  forms,  with  the  central  corneal  area 
yellow  in  color  and  surrounded  by  intense  vascularization,  others  in  which 
there  is  a  combination  of  parenchymatous  keratitis  and  keratitis  punc- 
tata, and  that  form  which  is  spoken  of  as  central  annular  interstitial 
keratitis,  especially  described  b}^  Vossius,  and  usually  seen  in  indi- 
viduals under  the  age  of  twenty,  and  for  which  a  definite  cause  has  not 
been  found.  The  variety  which  begins  as  a  marginal  vascular  keratitis 
has  been  described.  It  is  difiicult  to  distinguish  precipitates  in  Des- 
cemet's  membrane  in  this  disease  from  dot-like  lesions  in  the  deeper  layer 
of  the  cornea.  Parenchj^matous  keratitis  does  not  always  begin  pri- 
marily in  the  cornea.  Iritis  and  iridocychtis  or  rarely  episcleritis  may 
preceed  the  corneal  disease  which  then  must  be  regarded  as  a  secondary 
manifestation. 

Prognosis. — From  six  to  eighteen  months  are  usually  consumed  in 
the  development  of  the  various  stages  of  the  disease.  The  second  eye 
is  almost  certain  to  be  attacked  in  from  a  few  weeks  to  two  months; 
even  active  medication  may  not  prevent  the  involvement  of  the  second 
eye.  In  rare  instances  the  interval  is  mam^  months,  even  a  year;  it 
may  be  delayed  from  five  to  six  years.  The  patient  or  his  friends  must 
be  warned  of  this  fact. 

A.  return  to  perfect  transparency  is  unusual.  The  vessel  formation 
in   the    cornea   rarely    subsides    entirely,    but    even   long-continued 


292  DISEASES    OF   THE    CORNEA 

opacity  in  the  course  of  time  may  markedly  lessen,  and  reasonable 
vision  be  restored,  especially  if  the  refractive  error  (often  myopia  and 
astigmatism)  is  carefully  corrected.  The  occasional  onset  of  deep- 
seated  inflammation  of  the  cihary  region,  and  the  fact  that  after  the 
cornea  has  cleared  evidences  of  choroiditis,  retinitis,  or  disease  of  the 
optic  disk  and  glaucomatous  cupping,  may  be  discovered,  must  not 
be  forgotten  in  rendering  a  prognosis. 

Relapses  are  frequent  (18  to  22  per  cent,  of  the  cases,  accortling 
to  Hoor),  not  only  of  the  corneal  di.sease,  but  of  the  complications 
found  in  the  iris  and  retina.  Von  Szili  suggests  that  the  relapses  may 
be  due  to  anaphylaxis,  to  which  he  also,  in  part,  attributes  the  de- 
velopment of  the  disease  after  traumatism.  It  has  l)een  taught  by 
some  observers  that  the  disorder  is  more  severe  now  than  in  former 
times. 

Pathology. — The  principal  changes  occur  in  the  th^eper  layers  of 
the  substantia  propria  of  the  cornea,  and  consist  essentially  of  dense 
infiltrations  of  these  areas.  Xewly  formed  blood-vessels-  are  seen  in 
the  posterior  and  middle  layers,  and  there  may  be  nodular  collections 
of  lymphocytes  (Fuchs).  Some  authorities  distinguish  between  prim- 
ary and  secondary  interstitial  keratitis,  the  latter  being  associated  with 
inflammation  of  the  uveal  tract.  Leber  regarded  the  disease  as  always 
secondary  to  a  uveitis,  and  this  view  is  strengthened,  according  to 
Parsons,  by  reason  of  the  frequency  with  which  anterior  choroiditis 
can  be  found  ophthalmoscopically  in  the  less  affected  eye,  and  by  such 
microscopic  examinations  which  have  been  made.  Some  authors 
(E.  von  Hippel,  Elschnig,  Stock)  believe  that  this  parenchymatous 
keratitis  is  primarj^ — i.  e.,  that  the  corneal  disease  is  the  direct  result 
of  the  general  infection.  Igersheimer  is  persuaded  that  this  disease, 
at  least  in  most  cases,  is  independent  of  anterior  uveal  tract  inflamma- 
tion and  in  so  far  as  clinical  observations  are  concerned  slK)uld  as  a  rule 
be  considered  as  a  specific  parenchymatous  disease  of  the  cornea. 
Other  observers  (Stephenson)  ascribe  the  corneal  affection  to  an  exten- 
sion of  the  process  from  the  uveal  tract;  that  is,  in  syphilitic  ca.ses,  the 
spirochetes,  arriving  from  this  area,  prolifcM'ate  in  the  corneal  tissue. 
Refei-ring  especially  to  sypiiilitic  parenchymatous  keiatitis,  two  views 
in  regard  to  the  nature  are  maintained,  either  that  it  is  due  to  the  direct 
action  of  .th(;  spirochetes  which  have  been  found  in  the  cornea  (K.  von 
Hippel,  Clausen,  Igersheimer),  or  that  it  is  an  indirect  manifestation  of 
syphilis,  i.  e.,  a  para-  or  meta-sypliilitic  affection.  K.  von  Hippi^l.  in 
some  histologic  investigations,  found  no<lules  in  the  cornea  contaiiiing 
epilhclioid  and  giant  cells.  Injections  of  tuberculin  T.  cause  a  local 
reaction  in  some  of  the  cases,  which  sugg<>sts  a  tuberculous  nature 
of  the  process. 

Anaphyldclic  Iccrdlilis  has  hccii  itroduccd  by  Wesscly,  von  Szili.  and 
Arisawa  which  closely  rcscinlilcs  human  interstitial  keratitis.  Thus, 
Wessely  obtained  these  results  by  injecting  2  drops  of  sterile  horse 
serum  between  the  lamella'  of  one  cornea,  followed  in  fourteen  days 
\>y  a  similar  injection  betwe<'n  I  he  lamella'  of  the  other  cornea.      \'on 


i 


PARENCHYMATOUS    KERATITIS  293 

Szili  and  Arisawa  produced  opacity  and  vascularization  in  a  cornea 
sensitized  fourteen  days  previously  bj^  means  of  an  injection  into  the 
auricular  vein.  It  is  not  impossible  that  interstitial  keratitis  should 
be  regarded  as  an  anaphylactic  phenomenon.  Thus,  Derby,  Walker, 
Igersheimer,  and  Schoenberg  reason  that  the  spirochetes  or  their  toxins 
may  sensitize  the  cornea  during  extra-  or  intra-uterine  life.  If  later, 
during  childhood,  a  new  amount  of  latent  syphilitic  virus  enters  the 
previously  sensitized  cornea,  keratitis  results. 

Treatment. — All  irritating  applications  are  harmful.  Atropin,  to 
maintain  mj-driasis,  prevent  iritis,  and  allay  inflammation,  should  be 
systematically  employed,  unless  rise  of  tension  appears,  when  it  must 
be  discontinued.  Dionin  is  of  distinct  service.  The  frequent  use  of 
hot  fomentations  is  useful,  and  tenderness  in  the  ciliary  region  will  be 
reheved  by  a  leech  applied  to  the  temple  in  subjects  of  suitable  age. 
The  eyes  may  be  protected  from  dust  and  light  by  goggles  or  a  dark 
shade. 

A  long-continued  course  of  mercury  is  indicated.  The  most  satis- 
factory method  of  administration  in  the  earlier  stages  is  by  inunctions, 
1  dram  (3.885  gm.)  of  the  ointment  rubbed  into  the  skin  once  or  twice 
a  day,  according  to  circumstances.  ]\Iercury  with  chalk,  1  grain  (0.065 
gm.)  three  times  a  day,  is  highly  recommended.  Subconjunctival  in- 
jections of  bichlorid  of  mercury  have  been  advocated,  but  in  the 
author's  experience  have  proved  an  unsatisfactory  method  of  admin- 
istering mercury  in  this  disease.  Similar  injections  of  cyanid  of 
mercury  have  been  employed.  Injections  of  saline  solutions  are 
often  of  decided  advantage.  L.  Webster  Fox  advises  subconjunc- 
tival injections  of  sodium  saccharinate  (1  to  3  per  cent.).  Some 
surgeons  recommend  that  mercury  be  given  in  the  form  of  hypo- 
dermic injections.  An  experience  with  this  plan  of  treatment  of  this 
disease  has  not  caused  the  author  to  abandon  the  usual  methods  of 
administration. 

During  the  time  the  inunctions  are  being  employed,  cod-liver  oil 
may  be  exhibited;  later,  bichlorid  of  mercury  is  a  valuable  remedy,  and, 
as  many  of  the  patients  are  anemic,  this  is  advantageously  combined 
with  the  tincture  of  the  chlorid  of  iron.  Arsenic  is  useful,  and  atoxyl 
is  highly  recommended  by  Stephenson  in  doses  of  0.25  to  0.50  gram, 
injected  in  the  muscles  of  tlie  back  once  or  twice  a  week.  A  course 
of  tonic  treatment,  nourishing  diet,  exercise,  and  healthful  sur- 
roundings are  necessary;  in  short,  all  measures  are  indicated  which 
elevate  the  standard  of  the  patient's  general  health.  Indeed,  it  is 
most  important  to  treat  the  subjects  of  this  disease  most  carefully  from 
the  dietetic  standpoint.  Injections  of  tuberculin  T.  in  those  cases  de- 
pending upon  tuberculosis  have  proved  to  be  efficient.  They  should 
be  administered  according  to  the  methods  described  on  page  341. 
The  subjects  of  parenchjmiatous  keratitis,  even  though  syphilitic,  may 
have  disturbances  of  the  internal  secretion.  The  administration  of 
thyroid  extract  in  some  types  of  this  disease  possess  distinct  advantage. 

Much  difference  of  opinion  exists  as  to  the  value  of  salvarsan  and 


294  DISEASES    OF   THE    CORNEA 

neosalvarsan  (or  their  equivalent,  arsphenaininj  in  the  treatment  of 
interstitial  keratitis  of  luetic  origin.  In  the  author's  experience  this 
form  of  medication  is  most  valuable,  and  in  sj-philitic  patients  it 
quickly  causes  a  subsidence  of  the  irritative  phenomena.  Although 
it  does  not  materially  hasten  the  absorption  of  the  corneal  deposits 
it  definitely  shortens  the  duration  of  the  disease.  The  injections  of 
neosalvarsan  are  given  at  intervals  of  one  to  two  weeks;  usually  small 
doses  are  employed.  During  the  intervals  the  medication  should  con- 
sist in  mercurial  inunctions,  iodid  of  potassium,  or  mixed  treatment. 
The  dose  of  salvarsan  must  be  regulated  according  to  conditions  and 
symptoms;  usually  each  dose  should  be  0.4  gram.  Sometimes  0.2 
gram  will  suffice. 

When  all  irritation  has  subsided,  clearing  of  the  remaining  opacity 
is  facihtated  by  the  use  of  a  salve  of  the  yellow  oxid  of  mercury,  to- 
gether with  massage  of  the  cornea,  or  by  the  local  use  of  a  solution  of 
iodid  of  potassium.  Subconjunctival  saline  injections  may  facihtate 
the  absorption  of  the  corneal  opacities.  Iridectomy,  if  the  tension  rises 
and  glaucoma  threatens,  may  be  necessary;  it  is  evident  that  it  should 
be  employed  for  new  pupil  if  a  stubborn  central  opacity  remains. 

Keratitis  Punctata  Syphilitica  {Keratitis Punctata  Vera  [Mauth- 
ner;;  Keratitis  Intersiitialis  Punctiformis  Specifica  [Hock];  Keratitis 
Punctata  Profunda  [Fuchs]). — This  form  of  keratitis  was  originally'  de- 
scribed by  Mauthner,  and  is  characterized  by  the  appearance  of  cir- 
cumscribed, pin-head  sized  grayish  spots  in  the  parenchyma  of  the 
cornea;  episcleral  injection  is  usually  wanting.  The  iris  is  not  involved, 
the  overlying  cornea  appears  transparent,  and  the  dots  may  arise 
quickly  and  disappear  rapidly  without  leaving  a  trace.  They  probably 
indicate  a  gummatous  infiltratio7i  of  the  cornea  (more  cireumscribed 
gummatous  infiltration  or  gumma  of  the  cornea  has  been  described). 
This  disease  is  a  rare  manifestation  of  syphilis  in  its  later  stages,  and 
should  be  treated  with  the  usual  antisyphilitic  remedies. 

Trypanosoma  Keratitis.— The  oeular  manifestations  of  trypa- 
nosomiasis in  man  have  been  studied  by  IMorax,  H.  Leber,  A.  Lavi'ran 
and  Pettit  and  a  number  of  others  and  include  iritis,  chorioretinitis 
and  parenchymatous  keratitis.  Trypanosome  keratitis  has  been 
experimentally  produced  (Stock  and  others).  The  author  and  Alan 
Woods  used  the  trypanosoma  eijuiperdum  in  their  experiments  and 
produced  a  typical  parenchymatous  keratitis — also  iritis  and  retinitis. 
The  corneal  symptoms  were  always  synchronous  with  the  appearance 
of  trypanosomes  in  the  aqueous  tumor.  The  ocular  lesions  yield  (in 
animals)  to  repeate(l  inject  ions  of  salvarsan. 

Keratitis  punctata  is  charaftc^vized  l)y  a  j)recipitate  of  opaque 
dots,  generally  arranged  in  a  triangular  manner,  upon  the  posterior 
elastic  lamina  of  the  cornea  (Desceni(>t's  membrane — hence  also  calhnl 
descemetitis) .  The  overlying  cornea  is  hazy,  its  surface  at  timesslightly 
uneven.  This  affection  is  always  secondary  to  disease  of  the  iris, 
ciliary  bod}',  choroid,  or  vitreous,  and  iience  is  a  symptom  and  not  a 
specific  disease.     It   will  l)e  fully  considered  elsewhere  (see  page  349). 


KERATITIS    SUPERFICIALIS    PUNCTATA  295 

Keratitis  Profunda  (Central  Parenchymatous  Infiltration;  Circum- 
scribed Parenchymatous  Keratitis). — This  form  of  keratitis  is  charac- 
terized by  the  formation  of  a  grayish  opacity  in  the  deeper  layers  of  the 
cornea,  sometimes  without  severe  irritative  symptoms  and  unassoci- 
ated  with  ulceration. 

The  cause  is  not  always  discoverable;  sometimes  alcoholic  excess, 
cold,  rheumatism,  and  malaria  may  originate  the  disorder;  it  undoubt- 
edly may  develop  from  an  injury.  W.  T.  Holmes  Spicer  beheves  that 
overeating  and  drinking  and  their  results  in  the  individuals  or  in  their 
descendants,  in  the  form  of  gout  and  rheumatism,  with  defective  intes- 
tinal functions,  are  responsible  for  the  majority  of  the  cases.  The  disease 
is  probably  an  expression  of  gastro-intestinal  auto-intoxication  in  some 
cases.  A?i  acute  interstitial  keratitis  in  association  with  mumps  has  been 
described  and  deep  infiltrates,  therefore  a  form  of  keratitis  profunda, 
may  be  one  of  the  complications  of  herpes  zoster  ophthalmicus 
(page  173). 

The  following  is  Fuchs'  description  of  this  disease:  The  gray 
opacity,  usually  in  the  center,  is  covered  by  the  superficial  corneal 
layers,  which  are  hazy  and  stippled,  but  not  absorbed.  Close  exami- 
nation (with  a  loupe)  of  the  corneal  opacity  resolves  this  into  individual 
points,  spots,  or  gray  interlacing  stripes.  The  deposit  slowly  absorbs 
without  ulceration,  and  commonly  with  only  slight  vesicle  formation, 
and  leaves  the  cornea  clear,  or  permanent  opacity  may  remain.  Symp- 
toms of  inflammation  may  or  may  not  be  present;  there  is  hyperemia 
of  the  iris.  The  duration  of  the  disease  is  from  one  to  twelve  months, 
the  average  duration  being  about  three  months. 

Spicer  thus  summarizes  the  symptoms  of  deep  keratitis:  Moderate 
ciliary  congestion,  moderate  vascularization,  but  no  salmon  patch, 
opacification  of  the  cornea,  either  as  a  central  disk  or  a  peripheral  cone, 
an  appearance  under  loupe  examination  of  fine  striated  hues,  and 
edema  of  the  cornea.  Fluorescein  causes  the  deepest  parts  of  the 
cornea  to  take  on  a  stain.  He  believes  that  the  true  seat  of  the  disease 
is  in  the  nutrient  blood-vessels. 

The  treatment  requires  atropin,  dark  glasses,  and,  later,  yellow  oxid 
or  similar  salve  to  aid  resolution.  Dionin  and  subconjunctival  injec- 
tions of  salt  or  cyanid  of  mercury  may  be  tried.  The  constitutional 
treatment  is  most  important,  and  is  governed  by  the  probable  cause. 

Among  the  more  uncommon  forms  of  corneal  inflammation  the 
following  may  be  mentioned : 

Keratitis  Superficialis  Punctata  (Keratitis  Subepithelialis  Cen- 
tralis; Keratitis  Maculosa;  Noduli  Cornece;  Relapsing  Herpes  Cornece) . — 
This  disease  appears  in  several  forms,  just  as  it  has  been  described 
under  several  names,  either  different  types  of  the  same  disorder  or 
closely  analogous  manifestations. 

Generally  it  begins  with  the  symptoms  of  a  sharp  conjunctivitis  in 
which  the  secretion  is  watery,  while  at  the  same  time  there  is  catarrhal 
disease  of  the  respiratory  tract.  In  two  or  three  days  numerous  small 
punctiform  or  linear  spots  appear,  not  immediately  beneath  the  epi- 


296  DISEASES    OF   THE    CORNEA 

thelium,  but  below  Bowman's  membrane.  The  overlying;  cornea  is 
slifi;htly  hazy,  and  the  epithelium  above  the  spots  a  httle  elevated,  the 
foci  being  more  numerous  near  the  center  of  the  cornea  than 
at  the  periphery.  The  cornea  between  the  spots  is  somewhat 
hazy,  and  contains  small  points  and  gray  Hnes  radiating  hither  and 
thither,  comparable  to  the  fine  fissures  in  ice.  The  disease  is  tedious 
and  may  last  for  months.  Generally  it  occurs  in  young  individuals, 
usually  is  bilateral,  and  is  unaccompanied  by  loss  of  epithelium,  ulcers, 
iritis,  or  hypopj'on.  In  some  cases,  however,  which  at  least  begin  with 
all  the  typical  signs  of  superficial  punctata  keratitis,  in  the  course 
of  the  disease  there  may  be  periods  during  which  the  fluorescein  test  will 
reveal  many  points  which  take  in  the  stain.  They  do  not  seem  to 
require  a  separate  classification. 

Stellwag  described  foci  of  large  size,  most  connnonly  in  the  peri- 
phery. This  type  of  the  disease  begins  with  pain  in  the  brow,  and 
the  iris  may  be  involved  (fmm?n)dar  keratitis).  It  is  analogous  to 
interstitial  forms  of  keratitis.  In  his  cases  the  duration'  was  much 
shorter,  cure  having  been  effected  in  two  weeks. 

Cause. — The  anatomic  nature  of  the  spots  is  uncertain;  by  some 
observers  they  have  been  believed  to  be  enlarged  and  opaque  corneal 
corpuscles,  or  lymph-s])aces  filled  with  opa(iU(»  matter.  The  disease 
ma}'  be  associated  with  catarrhal  and  other  affections  of  the  upper  air- 
passages.  It  has  also  been  observed  in  association  with  menstrual 
disorders  (Bosser),  with  recurrent  fever  (Trantas)  and  with  influenza, 
but  its  exact  nature  is  unknown.  Verho(>fT's  investigations  lead  him 
to  regard  the  affection  as  a  neuro[)athic  keratitis,  witii  the  causal 
lesion  in  the  cihary  gangUon.  The  infiltrations  beneath  Bowman's 
membrane  he  attributes  to  the  action  of  pyogenic  diffusible  toxic 
substances  arriving  at  nerve  terminals.  The  disease  iliffers  from 
herjx's  in  the  absence  of  vesicle  foiniation  and  luMpes  of  the  face,  in 
its  bilateral  character,  and  in  the  great  number  of  corneal  spots  or  foci. 
Treatment. — This  should  be  directeil  to  the  nuicous  membrane  of 
the  nasopharynx  as  well  as  to  the  eye.  Locally,  during  the  state  of 
irritation,  atropin  is  indicated,  and  later  yellow  oxid  ."^alve.  Holocain 
and  dioniii  are  of  .service.  Full  doses  of  ([uinin  would  seem  to  be 
called  for,  the  salicylates  and  aspirin  are  valuai)l(>  and  it  has  been 
reconunended  to  use  the  constant  cuii-eiit  along  the  region  of  the 
distribution  of  the  supra-orbital  nci\('. 

Superficial  Linear  Keratitis. This  unusual  disea.se,  as  d(>- 
scribcd  by  Spiccr  and  ( JncNcs,  generally  observed  in  young  adults, 
preceded  by  i)ain  and  congestion,  consists  in  the  formation  of  double 
contoured  lines,  rai.sed  ai)ove  the  surface  of  the  cornea.  .Moiig 
these  ridges  are  denser  s])ots  or  nodes  which  somctiiiics  slain  with 
fluorescein.  The  lines  arc  due  to  wrinkling  of  Hownian's  membrane 
and  the  formation  of  new  lil)r«)us  tissue  in  (he  adj.MceiU  sul>sl;intia 
|)r()pria.  Hue  to  tlir  fctldinj;  t)f  Desccmel's  membrane  llicre  is  ;ilways 
marked  lowciing  of  the  terLsion  of  the  eye-ball  (li>  potony).  The 
lines  may  be  \(  rlical  or-  nearly  .sound  have  slightly  pointi'd  ends:  some- 


KERATITIS    DISCIFORMIS  297 

times  they  cross  each  other  roujihly  and  resemble  letters.  The  disease 
may  run  a  mild  course,  or  be  severe  and  subject  to  relapse  in  which  case 
permanent  opacities  may  result.  It  is  possible  this  affection  is  akin  to 
dendritic  keratitis  (page  269),  but  the  disposition  and  form  of  the 
lesions  are  different. 

Treatment. — The  usual  treatment  of  atropin,  hot  compresses,  dionin, 
holocain  and  appHcations  of  alcohol  may  be  tried,  but  often  the  results 
are  disappointing. 

The  author  has  not  in  this  country  seen  an  affection  exactly-  similar 
to  the  one  just  described.  Haab  has  reported  a  form  of  keratitis  in 
which  lines,  also  double-countoured,  cross  and  recross  each  other  so 
that  the  appearance  of  the  letters  is  produced,  ^vhich  he  calls  Alphabet 
Keratitis  and  which  should  probably  to  regarded  as  a  process  similar 
to,  if  not  exactly  Uke,  the  linear  keratitis  of  Spicer  and  Greeves. 

Keratitis  Marginalis  Profunda. — Under  this  name,  which  is  here 
used  in  a  sense  quite  different  from  that  employed  on  page  299,  Fuchs 
has  described  a  rare  form  of  keratitis  in  which  a  yellowish-gray  zone  of 
opacit}',  immediateh'  joining  the  sclera,  pushes  into  the  clear  cornea, 
accompanied  by  inflammatory  symptoms,  and  occupies  about  one- 
half  of  the  corneal  circumference.  The  vessels  of  the  limbus  cover 
the  opacity;  in  several  weeks  these  and  the  inflammatory  symptoms 
subside,  leaving  a  rim  of  infiltration  somewhat  like  an  arcus  senilis, 
save  only  that  it  joins  the  sclera  directly  and  is  not  separated  from 
it  by  a  stripe  of  clear  cornea.  The  disorder  is  unaccompanied  by 
ulceration  except  in  rare  instance.  It  occurs  generalh'  in  old  people 
and  usually  in  one  eye  only,  rareh'  in  both. 

It  should  not  be  mistaken  for  the  angular  corneal  opacity,  which 
appears  in  connection  with  scleritis,  and  which  is  known  as  sclerotizing 
keratitis  (see  page  314) ;  it  differs  from  it  in  the  absence  of  any  preceding 
scleritis. 

Keratitis  Pustuliformis  Profunda.^ — This  unusual  form  of  kera- 
titis, described  by  Fuchs  is  usuall}'  encountered  in  elderly  persons  and 
generally  in  men.  Its  lesions  consist  in  variously  placed  and  sized 
yellow  deposits  deep  in  the  cornea  and  usually  surrounded  by  grayish 
opacity  similar  to  that  seen  in  parenchymatous  keratitis.  Iritis  is 
always  present  and  precipitates  on  Descemet's  membrane  and  hypopyon 
may  be  in  association  with  the  condition.  The  cause  of  the  disease  is 
not  known;  it  appears  to  be  syphilis  in  some  cases.  The  course  of 
the  affection,  one  eye  only  usually  being  aSected,  is  tedious.  Resolu- 
tion may  take  place,  but  generally  permanent  opacities  remain  and 
even  flattening  of  the  cornea.  Evidently,  according  +o  Fuchs,  a  toxin 
derived  from  the  inflamed  iris  attacks  the  cornea  from  behind.  Treat- 
ment has  proved  to  be  of  little  avail. 

Keratitis  Disciformis  (Keratitis  Annularis  et  Disciformis). — 
According  to  Fuchs,  this  is  an  individual  type  of  ring-like  or  disk-like 
keratitis.  Verhoeflf  believes  that,  as  it  may  be  produced  by  a  variety'  of 
causes,  from  the  etiologic  standpoint  it  is  not  an  entity.  It  should  be 
distinguished  from  the  annular  keratitis  of  Vossius  (see  page  269). 


298  DISEASES    OF    THE    CORNEA 

The  disease  is  usually  found  in  persons  in  middle  life  (in  Weeks' 
statistics  the  youngest  patient  was  eleven  years  of  age  and  the  oldest 
sixty-two)  and  appears  frequently-  after  slight  epithelial  defects, 
whether  these  are  caused  by  injury  or  by  herpes  of  the  cornea.  It  is 
characterized  by  a  delicate  gray  disk  which  occupies  nearly  the  middle 
of  the  cornea,  and  which  is  separated  from  its  transparent  margin  by  an 
intensely  gray,  sharply  marked  border.  The  superficial  layers  of  the 
cornea  arc  smooth  aiid  unirritated.  In  the  course  of  the  disease,  which 
lasts  usuall}'  for  several  months,  small  ulcers  may  appear,  and  in  most 
circumstances  there  is  a  decided  opacity  after  the  subsidence  of  the 
disease.  Fuchs  thinks  that  this  disease  has  a  position  between  serpigi- 
nous ulceration  and  the  flat,  disk-shaped  ulceration  after  herpes  of 
the  cornea  (sec  page  285).  All  three  depend  upon  an  infection  of 
the  cornea  which  gains  entrance  through  a  breach  in  the  epithelium. 
The  difference  depends  upon  whether  there  is  a  deep  or  a  superficial  in- 
volvement of  the  tissue,  which,  in  its  turn,  depends  probably  upon 
the  character  of  the  bacteria.  Peters  emphasizes  the  connection 
between  this  form  of  keratitis,  corneal  erosions,  and  serpent  ulcer, 
and  believes  that  all  three  depend  upon  a  nervous  lesion  affecting  the 
corneal  epithelium,  followed  by  edema  of  the  tissue.  Verhoeff  con- 
tends that  the  disease  is  neuropathic  in  origin.  Schirmer  has  described 
circumscribed  parenchymatous  keratitis,  exactly  resembhng  keratitis 
disciformis,  due  to  infection  with  vaccine  virus.  The  treatment  may 
include  atropin,  hot  compresses,  and  the  local  application  of  absolute 
alcohol,  but  it  has  not  been  followed  by  encouraging  success.  Dionin 
should  be  tried.  Weeks  finding  tuberculin  therapy  valuable  in  the 
treatment  of  this  disease  thinks  it  may  be  tuberculous  in  origin. 

Qrill=like  Keratitis  or  Corneal  Opacity  {Gittrige  Keratitis, 
Bibcr,  Haab);  Nodular  or  Quttate  Opacities  of  the  Cornea  (Groe- 
nouw,  Fuchs);  Family  Punctate  Degeneration  of  the  Cornea 
(Fehr). — Grill-like  corneal  opacity,  known  also  under  the  name  of 
trellised  and  lattice-form  opacity  of  the  cornea,  was  first  described  by 
Biber  and  Haab,  and  has  been  well  investigated  by  Freund.  The 
last-named  author  gives  to  these  opacities  the  following  characteristics: 
They  constitute  a  hereditary  disease  whicii  ajipcars  first  after  the  age  of 
puberty,  in  the  form  of  gray,  sup(>rficially  placed  spots  in  and  around 
the  center  of  the  cornea,  which  lie  beneath  the  epithelium  and  lift  it 
into  a  position  of  distinct  unevenness  on  the  superficial  layers  of  the 
cornea,  and  by  diffuse  corneal  ojiacity  which,  examined  with  a  loupe, is 
seen  to  be  composed  of  a  grill-like  network  with  radial  opacities.  The 
peripheral  borders  of  the  cornea  are  free  from  dis(>ase. 

Nodular  or  guttate  opacities  of  the  cornea  were  lirst  described  by 
Groenouw  and  later  investigated  by  Fuchs.  According  to  these 
authors,  the  disease  consists  in  the  ih^velopment  of  numerous  small, 
rounded,  or  irregular  gray  opacities  in  \\\v  cornea,  esjM'i-ially  within 
the  pupillary  area.  Between  the  larger  opacities  lie  much  smaller, 
dust-like  gray  points.  The  epithelium  is  slightly  raised  by  the  larger 
nodes,  ami,  therefore,  there  is  a  certain  slight  irregularity  of  the  corneal 


CALCAREOUS   DEGENERATION    OF   THE    CORNEA  299 

surface.  Almost  all  of  the  cases  have  occurred  in  men,  and  they  were 
not  found  to  be  associated  with  any  constitutional  disease.  In  some 
of  the  patients  a  history  of  previous  corneal  inflammation  was  ob- 
tained.' Reticular  opacities  and  interstitial  punctate  opacities  are 
names  also  sugo-ested  for  this  disease. 

With  the  name  "family  punctate  degeneration  of  the  cornea," 
Fehr  has  described  a  punctate  opacity  of  the  cornea  which  may  affect 
several  members  of  one  family,  and  which  begins  about  the  tenth  or 
twelfth  year  of  life,  progressing  steadily  until  toward  middle  life.  The 
cornea  presents  a  diffuse  gray  appearance,  and  is  strewn  with  white 
spots  and  dots  of  various  shapes  in  the  center,  while  the  periphery 
remains  comparatively  clear.  With  a  strong  lens  the  diffuse  opacity  is 
seen  to  be  composed  of  minute  points,  by  the  condensation  of  which 
the  larger  opacities  are  formed.  The  corneal  surface  is  smooth,  re- 
flects evenly,  and  has  normal  sensibility.  Although  this  corneal  condi- 
tion differs  somewhat  from  the  two  previous  ones  just  described,  it 
evidently  is  analogous,  as  Fehr  points  out,  to  them,  and  he  suggests 
that  these  lesions  probably  represent  three  different  types  of  the  same 
affection,  for  which  he  proposes  the  name  "family  punctate  or  spotted 
degeneration  of  the  cornea." 

These  various  processes  represent  a  degeneration  rather  than  an 
inflammation,  and  the  opacities  are  probably  due  to  deposits  of  hyalin 
material  in  the  deeper  layers  of  the  corneal  epithelium  and  in  Bow- 
man's membrane.  There  may  also  be  a  mucoid  substance  produced  by 
degeneration  of  the  corneal  lamellae.  Nodular  opacities  of  the  cornea 
(Groenouw)  are  regarded  by  Wehrli  as  a  form  of  chronic  tuberculous 
disease  of  the  anterior  layers  of  the  cornea  (lupus  of  the  cornea) . 
Treatment  is  absolutely  unavailing. 

Marginal  Degeneration  of  the  Cornea  (Senile  Marginal  Atro- 
phy).— This  is  probably  similar  to,  if  not  identical  with,  the  fur- 
row-keratitis  of  Schmidt-Rimpler,  and  has  been  well  studied  by  Fuchs, 
George  Coats,  and  a  number  of  observers.  It  occurs  in  middle-aged 
or  elderly  persons  in  whom  usually  an  arcus  senilis  becomes  wider  and 
the  cornea  in  the  area  of  the  arcus  grows  thin.  A  groove  or  gutter 
forms;  this  gives  way  before  the  intra-ocular  tension,  and  a  marginal 
ectasia  is  developed.  The  symptoms  of  irritation  are  mild;  sometimes 
the  lesions  are  unilateral,  sometimes  bilateral.  In  Zentmayer's 
patient  the  grooves  encircled  the  margin  of  the  cornea  of  each  eye 
except  for  an  arc  about  15  degrees  down  and  in.  Whether  the  process 
is  degenerative  or  inflammatory  has  not  been  decided.  Terrien  has 
tried  the  application  of  the  actual  cautery  for  its  relief. 

Primary  Progressive,  Calcareous  Degeneration  of  the 
Cornea. — Occasionally,  as  described  by  Axenfeld,  corneas  come  under 
observation  in  which  there  has  been  a  gradual  development  of  a  white 
calcareous,  ghttering  ring,  within  which  is  a  normal  area  corresponding 
roughly  to  the  size  of  the  pupil.  This  ring  reaches  to  the  temporal  and 
nasal  sides,  close  to  the  limbus,  but  is  separated  from  it  by  a  narrow, 
transparent  band.     Above  and  below  it  may  not  reach  so  near  to  the 


300  DISEASES    Of^    THE    CORNEA 

linibus  and  be  less  sharply  defined.  The  vision  ihrcjujih  the  eentral,  un- 
affected area  of  the  cornea  may  be  quite  good.  The  author  has 
studied  with  the  late  Dr.  Robin  of  New  Orleans  a  very  similar  I'a.-^e.  and 
has  also  seen  one  case  in  his  own  practice  in  an  adult  which  began  in 
comparative  youth.  Axenfeld  excised  a  portion  of  the  tissue  for  exam- 
ination, and  found  it  to  contain  highly  refractile  particles,  soluble 
in  acid,  from  which  solution  typical  calcareous  crj'stals  were  obtained. 
The  epithelium  was  practically  unaltered.  Other  progressive  degenera- 
tions of  the  cornea  are  the  chronic  degenerations  of  a  hyalin  type, 
degenerations  from  the  deposition  of  uric  acid  salts,  and  progressive 
fatty  degenerations.     (See  also  page  309.) 

Epithelial  Dystrophy  of  the  Cornea. — According  to  Fuchs,  this 
degenerative  disease  of  the  cornea  affects  only  elderly  persons,  being 
more  connnon  in  women  than  in  men;  it  has  also  been  noted  in  associa- 
tion with  tabes  dorsalis  by  Fuchs.  The  corneal  sensibility  diminishes, 
a  diffuse  opacity  of  the  cornea  develops  in  the  pupillary  area,  associated 
with  marked  alterations  in  the  ei)ithelium,  the  surface  of  which  is  un- 
even and  shows  blebs  or  small  dark  spots.  AMiile  the  epithelium  is  the 
chief  site  of  the  lesion,  there  is  also  stippling  in  the  deeper  layers  of  the 
cornea.  There  may  or  may  not  be  increased  intra-ocular  tension.  In 
two  patients  studied  by  the  author  the  disease  began  in  one,  a  man, 
eighteen  years  after  a  successful  cataract  extraction,  and  in  the  other, 
a  healthy  woman,  without  apparent  cause.  In  a  third  case  recently 
studied  added  to  the  corneal  changes  there  was  marked  rise  of  tension ; 
eserin  was  of  service.  All  the  typical  symptoms  recorded  by  Fuchs 
were  present.  Treatment  is  said  to  be  unavailing,  but  in  one  of 
the  author's  patients  the  persistent  use  of  dionin,  associated  with  the 
internal  administration  of  biniodid  of  mercury,  seemed  to  check  the 
process.     Duane  reconunends  the  administration  of  arsenic. 

Filamentous  Keratitis. — This  somewhat  unusual  condition  is 
characterized  by  the  development  of  small  threads  or  filaments  of  tissue 
on  the  cornea,  which  usually  appear  after  tibrasions  or  wounds  {trauma- 
tic filamentous  keratitis),  or  herpes,  or  occasionally  without  apparent 
cause  (spontaneoxis  filamentous  keratitis).  The  tags  have  a  bulbous 
extremity  and  are  often  twisted  like  a  rope.  They  start  from  small 
vesicles  by  tVie  formation  of  a  slender  jiedicle,  and  are  composinl  of 
epithelial  cells,  more  or  less  degenerated,  and  sometimes  especially 
elongated.  Torsion  of  the  filaments  is  due  to  the  movement  of  the 
eyelids.  A  number  of  them  may  be  found  in  a  single  cornea;  thus,  in  a 
case  reported  by  Zentmayer,  fifteen  to  twenty  of  thes(>  filaments  in 
various  stages,  some  as  clear  vesicles  attaciu'd  to  the  cornea  by  a  short 
pedicle,  others  as  filaments  .")  nun.  in  length  with  a  l)ull)ous  I'xtremity, 
were  noted.  They  may  speedily  (Hsa|)pear,  or  persist,  or  recur  alter 
remo\;il.      i-(ic;ill\',  liolocaiii  is  of  service. 

Riband-liUc  keratitis  (primanj  opacitij  of  Iff  cornea :\l ran sverse 
calcareous  hand  <tf  the  cornea:  zonular  opacilii:  keratitis  trochlea: 
keratitis  petrificans  [Suker])  appears,  :is  w.'is  pointeii  (»ut  by  Netlleship, 
in  two  forms: 


ARCUS    SENILIS  301 

In  the  one,  usually  in  elderly  people,  the  exposed  part  of  the  cornea 
is  invaded  in  a  transverse  direction  by  a  smooth  subepithelial  opacity, 
oval  in  shape,  which  can  be  chipped  off,  and  is  composed  of  an  incrusta- 
tion of  lime-salts.  Hyalin  deposits  also  appear  in  the  cornea.  There 
is  no  ulceration  and  no  change  in  the  overlying  epithelium.  The 
opacity  is  sharply  limited  and  the  remainder  of  the  cornea  is  clear. 
The  disorder  almost  invariably  is  symmetric,  and  is  situated  upon  the 
exposed  cornea,  although  deposits  like  the  transverse  band  may  also  be 
found  in  other  parts  of  the  cornea.  A  margin  of  the  cornea  at  each  end 
is  free.  Gout  and  excess  of  uric  acid  in  the  blood  have  been  suggested 
as  constitutional  causes,  a  suggestion  strengthened  by  the  occasional 
occurrence  of  insidious  iritis,  glaucoma,  and  hemorrhagic  retinitis.  It 
may  be  mistaken  for  the  opacity  which  occurs  from  the  injudicious  use 
of  salts  of  lead  (lead  incrustation  of  cornea).  Deep-seated,  pigmented, 
hand-like  opacity  of  the  cornea  has  been  described  (Schriinder),  and 
the  author  has  studied  recently  one  example  of  typical  bilateral 
zonular  opacities,  dark  brown  in  color;  no  cause  was  found;  the 
patient  is  an  elderly  woman. 

In  the  other  type  of  the  affection  a  horizontal  band  of  opacity, 
grayish-brown  in  color,  crosses  the  cornese  of  eyes  which  have  long  been 
blind  from  iridocyclitis,  sympathetic  ophthalmia,  and  glaucoma.  Here 
the  stripe  is  less  uniform,  less  sharply  defined,  and  consists  oi  a  rough- 
ened, transverse  opacity.  The  calcareous  nature  of  the  other  type  may 
be  wanting.  A.s  it  occurs  in  the  lower  third  of  the  cornea,  or  that  part 
exposed  when  the  eye  is  rolled  up,  and  in  an  eye  with  impaired  nutrition, 
the  affection  has  been  considered  trophic  in  its  nature.  According  to 
Best,  the  deposits  are  composed  of  lime  and  connective  tissue.  Hyalin 
globules  are  often  present. 

Blood=staining  of  the  Cornea. — This  phenomenon  has  been 
observed  in  cases  of  hyphemia  and  increased  intra-ocular  tension 
and  after  injuries.  It  is  not  a  frequent  phenomenon  (1  in  400  severe 
injuries  [Romer]).  The  cornea  assumes  a  smoky  or  rust-colored  tint, 
except  at  its  periphery,  the  clear  portion  being  sharply  separated 
from  the  cloudy  area,  which,  however,  is  usually  more  pronounced  in 
its  center.  The  appearances  closely  resemble  those  of  an  amber- 
colored  lens  dislocated  into  the  anterior  chamber.  With  the  micro- 
scope numerous  granules  (probably  hematoidin)  are  found  deposited  in 
the  substantia  propria,  which,  according  to  Griffith,  have  entered  the 
corneal  tissues  by  endosmosis  in  a  state  of  solution.  The  lesions  have 
been  studied  by  E.  T.  Collins,  Vossius,  Weeks,  and  J.  Griffith  and 
recently  by  Charles  Maghy;  according  to  the  observations  of  Collins 
and  the  author,  it  requires  at  least  two  years  for  the  stains  to  disappear. 

Arcus  senilis  {gerontoxon) ,  or  a  circle  of  fatty  degeneration  of  the 
substantia  propria  just  within  the  margin  of  the  cornea,  is,  as  its  name 
implies,  almost  invariably  found  in  old  persons.  A  true  arcus  is  always 
separated  from  the  adjacent  sclera  by  a  thin  stripe  of  clear  cornea. 
Occasionally  a  genuine  example  of  this  aTection  appears  to  have  been 
noted  in  children  (Hansell).     An  arciform  opacity,  the  result  of  ulcera- 


302  DISEASES    OF    THE    CORNEA 

tion,    may   be   mistaken   for  arcus  senilis.     The  nature  of  the  fatty 
material  in  arcus  senilis  has  not  been  determined  (Parsons). 

The  affection  requires  no  treatment,  and  its  presence  appears  not 
to  interfere  with  the  healing  of  wounds;  for  example,  in  cataract 
extraction. 

Senile  degeneration  in  the  form  of  sclerosis  and  atrophy  of  the  corneal 
margin,  which,  according  to  Fuchs,  may  arise  in  connection  with 
arcus  senilis,  has  l)een  described  on  page  299. 

Corneal  pits  (dellen)  have  been  described  by  Fuchs,  usually  at  the 
temporal  margin  of  the  cornea.  They  exist  in  the  form  of  small 
saucer-like  depressions,  and  may  arise  in  association  with  swelling, 
inflammatory  or  otherwise,  of  the  neighboring  conjunctiva,  or  spontane- 
ously.    They  last  from  a  few  hours  to  several  days. 

Conical  Cornea  (Keratoconus) . — This  consists  of  a  cone-shaped 
bulging  forward  of  the  cornea,  and  is  rarely  congenital.     It  has  been 

observed  in  several  members  of  the  same 
family.  Usually  stated  to  be  more  common 
in  women  than  in  men,  some  recent  statistics 
do  not  confirm  this  assertion.  It  occurs  most 
frequently  between  the  ages  of  fifteen  and 
thirty  years;  rarely  it  is  seen  in  children.  Its 
exact  cause  is  unknown.  Exhausting  illness, 
menstrual  disturbance,  and  especially  chronic 
dyspepsia  may  be  associated  with  the  develop- 
ment of  conical  cornea,  the  immediate  cause 
being  a  disturbance  in  the  relation  of  the  intra-ocular  pressure  to  the 
resistance  of  the  cornea,  that  is,  the  intra-ocular  tension  is  relatively  too 
high.  Minute  clefts  in  Descemet's  membrane  may  appear,  and  pulsa- 
tion of  the  cornea  synchronous  with  each  impulse  of  the  heart.  In 
the  study  of  keratoconus  von  llippel  has  applied  Abderhalden's  test 
and  found  a  disturbance  of  glandular  secretion,  an  observation  which 
has  also  been  made  by  Siegrist. 

The  cone"  is  transparent  in  most  instances;  occasionally  its  apex  is 
slightly  opaque.  The  bulging  slowly  progresses,  but  does  not  rupture. 
After  years  it  comes  to  a  standstill.  Ulceration  by  virtue  of  the 
increasing  conicity  of  the  cornea  apparently  does  not  occur,  but  an 
ulcer  adjacent  to  the  cone  may  develop  as  in  a  case  of  the  author's  where 
the  small  resulting  cicatrix  checked  progress  of  the  diseiise.  One  or 
both  eyes  may  be  involved,  commonly  the  latter,  the  second  eye  being 
affected  some  time  after  its  fellow.  The  eye  becomes  myopic  and  highly 
astigmatic.  Slight  forms  of  conical  cornea  may  be  overlooked  unless 
the  shadow-test  is  employed  and  the  characteristic  reflections  observed, 
or  a  Placido  disk  is  used  (see  page  50),  or  the  cornea  is  studied  with 
the  ophthalmometer  and  the  distortion  of  the  images  of  the  mires  is 
investigated. 

Treatment. — -Although  no  form  of  glass  or  no  optical  apparatus 
may  avail  in  advanced  cases,  a  can^ful  trial  should  always  be  made  with 
spherocylindric  lenses,  and  fre(iu(*ntly  their  employment   in  unusual 


INJURIES    OF    THE    CORNEA  303 

combinations  will  markedly  improve  visual  acuteness.  The  refraction 
should  be  frequently  investigated  and  the  lenses  changed  according  to 
existing  conditions.  The  tendency  for  the  cone  to  alter  and  increase  in 
size  seems  to  be  lessened  b}'  the  persistent  use  of  eserin  or  pilocarpin. 
The  strength  of  the  solution  need  not  be  greater  than  3^12  to  ^  grain 
(0.0054-0.0108  gm.)  to  the  ounce  (30  c.c).  The  administration  of 
thyroid  extract  has  been  advised. 

Properly  perforated  black  disks — that  is,  forms  of  artificial  iris — 
are  recommended  by  L.  Webster  Fox  for  the  relief  of  conical  cornea. 

If  the  apex  of  the  cone  appears  to  be  thinning,  a  weak  solution  of 
sulphate  of  eserin  and  a  compressing  bandage  are  indicated. 

In  advanced  cases  an  operation  is  advisable,  having  for  its  object 
the  substitution  of  a  contracting  cicatrix  for  the  tissue  at  the  apex  of  the 
cone,  which  shall  diminish  the  excessive  curvature.  Several  plans  are 
suggested:  (1)  Cutting  off  a  small,  superficial  flap  and  subsequently 
cauterizing  the  surface,  associated  with  repeated  paracentesis  of  the 
cornea,  and  later  a  small  iridectomy  for  optical  purposes;  (2)  cutting 
off  the  flap  and  drawing  the  edges  of  the  wound  together  with  delicate 
sutures;  (3)  cutting  from  the  apex  of  the  cone  a  small  disk  with  a  tre- 
phine; (4)  multiple  punctures  with  fine  needles;  (5)  obtaining  the  de- 
sired loss  of  substance  by  the  application  of  a  galvanocautery.  If  the 
resulting  scar  is  directly  central,  an  iridectomy  for  optical  purposes 
will  usually  be  requu-ed;  but  if  the  apex  of  the  cone  is  eccentric,  as  it 
often  is,  iridectomj"  will  not  be  required.  Elschnig  advises  that  the 
galvanocautery  shall  be  applied  at  a  dull-red  heat  to  the  apex  of  the 
cone,  and  this  area  connected  with  the  nearest  point  of  the  corneal 
hmbus  by  a  superficially  cauterized  band.  Optical  iridectomy,  accord- 
ing to  this  author,  is  not  necessary.     (See  also  page  692.) 

Injuries  of  the  Cornea. — Traumatic  Keratitis. — These  comprise: 
(1)  Foreign  bodies;  (2)  erosions:  (3)  wounds,  and  (4)  burns  and  scalds. 

Foreign  bodies,  as  particles  of  sand,  cinders,  fine  sphnters  of  iron, 
and  bits  of  emery,  may  either  lodge  upon  the  epithelium  or  become 
embedded  in  the  substance  of  the  cornea.  If  they  are  sharp,  like  a 
splinter  of  iron  or  small  thorn  from  a  chestnut-burr,  they  may  partially 
penetrate  the  membrane. 

The  pain  of  even  a  minute  foreign  body  is  considerable;  the  eye 
waters  and  grows  red,  and  the  source  of  irritation  is  commonly  referred 
to  the  under  surface  of  the  upper  hd,  althouhg  the  intruder  may  be 
directly  upon  the  center  of  the  cornea.  A  foreign  body  must  not  be 
wiped  from  its  position  with  a  probe  or  thin  stick  wound  with  dry 
cotton.  Such  a  procedure  almost  invariably  detaches  an  area  of 
corneal  epithelium  and  offers  a  port  of  entrance  to  microbic  infection 
whereby  an  ulcer  of  the  cornea  may  arise.  The  pernicious  practice, 
only  too  common  among  workmen,  of  attempting  to  remove  a  foreign 
body  by  means  of  a  tooth  pick  or  similar  unclean  instrument  cannot  be 
too  strongly  condemned. 

To  remove  an  embedded  foreign  body  a  drop  of  a  4  per  cent, 
solution  of  cocain  or  a  2  per  cent,  solution  of  holocain  is  instilled,  the 


304  DISEASES    OF    THE    CORNEA 

upper  and  lower  lids  are  held  apart  with  the  thumb  and  forefinger  of 
the  surgeon's  left  hand,  while  with  the  right  hand  he  takes  a  carefully 
sterilized  needle,  or  a  spud,  and  lifts  the  body  b}-  a  lever-like  motion 
from  its  position  with  as  little  injury  as  possible  to  the  cornea.  The 
area  should  afterward  be  inspected  by  means  of  a  2-inch  lens  and 
oblique  illumination.  In  any  case  in  which  the  operator  is  not  sure 
that  he  has  removed  the  foreign  substance  he  may  resort  to  the  fluores- 
cein method  described  on  page  50.  If  the  substance  has  been  iron  or 
emery,  a  small,  rust-like  spot  will  often  remain.  Powder  grains  may 
be  removed  by  touching  them  with  a  fine  galvanocauterj^  point  (E. 
Jackson). 

If  the  spicule  has  partially  penetrated,  it  may  be  necessary  to  pass 
a  broad  needle  through  the  cornea  behind  it  to  secure  a  surface  against 
which  to  work,  and  to  prevent  the  manipulations  from  pushing  it 
entirely''  through  the  cornea  and  into  the  anterior  chamber.  Some- 
times a  spicule  of  metal  in  these  circumstances  is  best  removed  by 
means  of  a  magnet. 

In  the  past  war  many  cases  of  multiple  foreign  bodies  were  observed 
due  to  peppering  of  the  cornea  with  fine  metallic  dust,  the  particles 
being  so  close  together  that  the  afifected  area  resembled  a  cornea 
which  had  been  tattooed  with  India  ink.  Under  such  conditions  indi- 
vidual removal  of  the  foreign  bodies  was  out  of  the  question.  Some- 
times the  bodies  were  graduall}^  exfoliated  and  later  those  which 
remained  were  removed  in  the  usual  way.  Fragments  of  unburnt 
cordite  becoming  embedded  in  the  cornea  and  conjunctiva  proved 
during  the  past  war  to  be  very  troublesome  and  dangerous. 

After  the  removal  of  the  foreign  body,  the  resulting  irritation  may 
be  allayed  by  a  drop  of  atropin;  the  use  of  a  bandage  for  a  few  daj'S 
will  facilitate  the  healing  of  the  abrasion.  Disinfection  of  the  con- 
junctival cul-de-sac  with  a  bichlorid  lotion  (1  :  8000)  or  one  com- 
posed of  cyanid  of  mercury  (1  :  2000)  is  important.  If  in  the  attempt 
to  remove  the  foreign  body  much  abrasion  of  the  cornea  has  occurred, 
great  care  should  be  exercised  to  prevent  infection.  Darier  recom- 
mends a  collyrium  of  cyanid  of  mercury  which  contains  dionin. 

Among  oyster-shuckers  a  form  of  keratitis  is  prevalent  {oystcr- 
shuckers'  keratitis),  caused  by  snuill  particles  of  oyster  shells  striking 
the  cornea  and  producing  uh-ers.  Haiulolph  shcjwed  that  the  disease 
depends  upon  the  irritating  chemic  ingredients  in  the  shell,  and  not 
upon  micro-organisms.  It  is  best  treated  by  atropin  and  mild  anti- 
septic lotions,  and  a  2  per  cent,  solution  of  holocain  in  physiologic  salt 
solution.  Kerato-iritis,  the  result  of  ;i  bec'-stin^,  has  b(>en  reported 
(Iluwald),  and  also  from  the  action  of  aiitipyrin  (^Inouye). 

Erosions. — A  superficial  loss  of  epitliclium  causcnl  by  the  contact  of 
a  sharp  body,  for  example,  a  finger-nail,  twig  of  brush,  beard  of  wheat, 
etc.,  in  itself  may  be  insignificant,  but  may  lead,  through  infection,  to 
a  severe  ulceration,  particularly  if  the  injured  (>ve  is  exposed  to  the 
discharge  from  an  inll.'itned  l;icrinioii;is;il  diu-t. 

The  Ircdlnunt  eonsisls  of  the  iiis|ill;it  ion  of  ;iii  antiseptic  lotion,  for 


INJURIES    OF    THE    CORNEA  305 

example,  bichlorid  of  mercury  (1  :  8000),  and  the  use  of  atropin  and 
holocain,  with  a  compressing  bandage  to  immobihze  the  hds  until 
heahng  takes  place,  provided  no  septic  discharge  is  present.  White's 
bichorid-\^aselin  ointment  is  valuable. 

Relapsing  Traumatic  Keratitis  Bullosa  (Relapsing  Erosion  of  the 
Cornea;  Traumatic  Keratalgia). — In  general  terms  the  symptoms  of  this 
affection  are  these:  Some  time — several  weeks  or  several  months — 
after  an  abrasion  of  the  cornea  by  a  finger-nail,  a  twig,  or  similar 
object,  the  patient  experiences,  almost  alwaj'^s  on  awakening  in  the 
morning,  some  difficulty  in  opening  the  eye,  followed,  when  the  lid  is 
raised,  by  marked  foreign-body  sensation,  decided  epiphora,  flushing 
of  the  eyeball,  and  sharp  neuralgic  pain.  Each  movement  of  the  lid 
is  painful,  and  the  "attack"  continues  from  one-half  hour  to  several 
hours,  when,  usually  by  afternoon,  the  symptoms  subside  and  the 
eye  is  again  apparently  normal.  Careful  examination  during  the 
continuance  of  the  irritative  signs  just  described  will  reveal  on  the 
cornea  a  small  ruptured  vesicle,  or  a  larger  blister  or  bulla,  or  some- 
times simply  an  erosion  of  the  superficial  epithelium,  without  indica- 
tions of  vesicle  or  bulla.  Occasionally  the  only  lesion  to  be  detected 
is  the  scar  or  macula  caused  by  the  original  injury,  without  loss  of 
epithehum.  These  attacks  may  recur  at  short  or  long  intervals,  for 
weeks,  months,  and  even  years. 

Treatment. — The  ordinary  treatment  of  corneal  ulcer  is  indicated, 
and  the  author  has  been  especially  satisfied  with  the  action  of  holocain 
(2  per  cent.),  persistently  and  frequently  used.  A  pressure  bandage 
and  massage  with  a  salve  of  yellow  oxid  of  mercury  may  be  tried.  A 
drop  of  liquid  vaselin  instilled  at  bedtime  is  useful. 

Wounds  of  the  cornea  naturally  divide  themselves  into  non-penetrat- 
ing and  penetrating,  and  differ  in  character  according  to  the  instrument 
which  has  inflicted  them. 

Non-penetrating  wounds  partake  of  the  nature  of  erosions,  and,  like 
them,  may  be  in  themselves  of  minor  importance,  but  may  result  in 
sloughing  ulcers  through  microbic  infection. 

The  treatment  already  described  is  applicable. 
A  penetrating  wound  allows  the  escape  of  the  aqueous;  incarcera- 
tion and  prolapse  of  the  iris  may  follow,  with  all  the  possibilities 
described  in  connection  with  perforating  ulcers.  The  wound  may 
injure  the  lens  and  cause  traumatic  cataract,  or  involve  the  ciliarj^ 
region  and  cause  sympathetic  inflammation,  or  become  infected  and 
originate  a  sloughing  keratitis  or  a  panophthalmitis. 

After  a  perforating  wound  of  the  cornea  the  eye  should  be  thor- 
oughly and  promptly  irrigated  with  bichlorid  of  mercury  (1  :8000) 
or  cyanid  of  mercury  (1  :2000)  and  care  must  be  taken  to  ascertain 
whether  a  foreign  body  has  lodged  within  the  anterior  chamber  or 
within  the  deeper  portion  of  the  globe.  a;-Ray  examination  may  be 
necessary.  The  iris,  if  prolapsed,  and  if  replacement  is  not  possible, 
and  usually  it  is  not  advisable  to  attempt  it,  should  be  seized  with 
iris  forceps  and  excised.     Unless  the  coaptation  of  the  corneal  wound 

20 


306  DISEASES    OF   THE    CORNEA 

is  absolutely  perfect,  a  conjunctival  flap  should  Ix'  miulv  to  cover  its 
situation. 

Gaping  central  wounds  of  the  cornea,  according  to  de  Wecker's 
method,  may  be  covered  with  conjunctiva,  which  is  dissected  loose  in 
such  a  manner  that  it  may  be  united  over  the  cornea  by  a  purse-string 
suture.  After  the  corneal  wound  has  united,  the  conjunctival  covering 
is  removed  and  restored  to  its  original  position.  Kuhnt's  conjunctival 
flaps  may  also  be  used  and  usually  more  satisfactorily  (page  081). 
The  tendency  to  traumatic  iritis  may  be  combated  by  the  frequent 
use  of  cold  compresses,  and  the  instillation  of  an  atropin  solution.  In 
severe  corneal  wounds,  involving  the  iris,  lens,  and  ciliary  bod}',  the 
question  of  enucleation  or  evisceration  must  be  decided. 

Bums  and  scalds  are  produced  by  the  contact  of  acids,  lime,  molten 
metal,  and  hot  water  or  steam,  and  the  general  management  of  such 
cases  does  not  differ  from  that  of  similar  accidents  to  the  conjunctiva, 
which  necessarily  is  involved  (see  page  257). 

Sometimes  the  burn  may  be  superficial  and  the  whole  surface  epi- 
thelium be  changed  into  a  white  scum,  which  presents  a  most  alarming 
appearance.  The  destroyed  tissue,  however,  is  speedily  replaced  by  a 
new  laj'er  of  epithelium.  Burns  with  slaking  lime  and  molten  metal 
are  liable  to  result  in  disastrous  consequences,  and  may  be  followed  b}' 
sloughing  keratitis  and  ev^en  panophthalmitis,  and  if  the  burns  are 
located  at  the  limbus,  elevation  and  intra-ocular  pressure  may  develop 
(Kiimmell).  AUport  and  Rochester  have  advantageously  used  intra- 
muscular injections  of  cacodylate  of  sodium  in  the  treatment  of  corneal 
opacity  following  a  lime  burn.  Ammonia  burns  of  the  eye  are  of  serious 
import,  and  even  where  the  injury  originally  seems  to  be  comparatively 
slight,  there  may  develop  later  rapid  necrosis  of  the  cornea,  with 
exudation  in  the  anterior  chamber,  followed  by  blindness.  There  is 
a  certain  similarity  between  carbolic  acid  buriis  and  those  caused  by 
ammonia,  but  the  ultimate  prognosis  is.  according  to  Stieren,  less 
gloomy. 

Severe  corneal  anil  conjunctival  burns  have  been  caused  by  ex- 
ploding golf-balls,  so-called  "zodiac"  and  "water-core"  balls,  contain- 
ing caustic  contents,  e.  g.,  barium  sulphate,  sodium  hj'drate,  soap,  free 
alkali,  and  zinc  chlorid.  The  treatment  of  burns  and  scalds  has  al- 
ready been  descril)ed  (see  i)age  257). 

All  the  various  forms  (jf  corneal  injury  cause  more  or  less  severe 
inflannuation,  properly  classed  under  the  general  term  traumatic  kera- 
titis, and  possesses  in  greater  or  less  degree  the  cardinal  symptoms  of 
keratitis^pain,  lacriniation,  ijhotojihobia,  and  disturbnni-e  of  vision 
(see  also  page  'Mi). 

Peripheral  Annular  Infiltration  of  the  Cornea  (/i*///(7  Altsccss 
of  the  Cornea).  'I'his  cDuditioii  is  i-lKuactcrizcd  by  an  intiltration  of  the 
cornea,  the  exudation  being  distrilnited  in  a  zone  concentric  with  the 
corncvil  margin.  At  first  the  ring  is  gray,  l)ut  rapidly  becomes  yellow, 
its  iiuier  edges  Ix'iiig  somcwliat  less  well  defined  than  its  outer;  in 
almost  all  cases  i):imi|»liliialniitis  is  the  ulliiuatc  n-sull.     The  condition 


TUMOES   AND    CYSTS   OF   THE    CORNEA  307 

most  commonly  follows  perforating  wounds  of  the  cornea,  especially  if 
caused  by  chips  of  metal,  and  operations,  for  example,  cataract  ex- 
traction. Karely  is  it  seen  after  perforating  corneal  ulcers  and  in 
metastatic  ophthalmitis.  It  has  been  well  studied  by  Fuchs  and 
by  Morax.  Bacteria  enter  the  anterior  chamber  through  a  wound  and 
there  proliferate,  and  by  their  products  give  rise  to  an  infected  irido- 
cyclitis and  keratitis;  the  cornea  is  attacked  from  the  rear  and  the 
condition  represents  its  reaction  to  the  toxins  acting  upon  its  pos- 
terior layers.  Leukocytic  infiltration  in  the  form  of  a  ring  follows, 
which  is  itself  amicrobic.  Hanke  believes  he  has  found  the  specific 
bacillus,  but  Morax  maintains  that  so-called  ring  abscess  cannot  be 
explained  by  the  presence  of  any  one  specially  determined  microbe, 
but  by  the  proliferation  of  certain  microbes  in  the  anterior  chamber, 
among  which  he  is  willing  to  admit  Hanke 's  bacillus. 

Traumatic  Striped  Keratitis  {Keratitis  Striata). — This  condition 
may  arise  after  incised  wounds  of  the  cornea,  and  in  its  most  perfect 
manifestation,  after  cataract  extraction  (see  page  742),  and  especiallj^ 
after  expression  of  the  lens  in  its  capsule  (see  page  735).  The  gray 
striae,  which  should  be  studied  w.ith  a  loupe,  are  disposed  perpendicularly 
to  the  wound,  and  stretch  toward  the  opposite  margin  of  the  cornea. 
Thej^  cause  no  irritation,  and  the  appearance  does  not  materially  com- 
plicate the  treatment  of  the  wound  which  gives  rise  to  them.  These 
stripes  do  not  represent  a  cellular  infiltration,  but  depend  upon  folds  in 
Descemet's  membrane.  Usually  they  disappear  within  a  week  of  their 
development. 

Obstetric  Injuries  of  the  Cornea. — These  injuries  may  be  due  to 
prolonged  labor  or  to  forceps  pressure.  The}'  have  been  particularly 
well  studied  by  Ernest  Thomson  and  Leslie  Buchanan,  who  classify 
them  as  diffuse  temporary  opacities  due  to  edema,  and  permanent  hnear 
opacities,  which  extend  vertically,  obliqueh',  or  horizontally  across  a 
whole  or  a  part  of  the  cornea,  and  which  are  caused  by  rupture  of  the 
posterior  elastic  lamina  of  the  cornea.  In  several  cases  of  the  edema- 
tous variety  studied  bj'  the  author  the  opacity  gradually  but  entirely 
disappeared.  Doubtless  some  of  the  scars  of  the  cornea,  known  as 
"congenital  leukomas,"  have  been  caused  b}'  birth  injuries.  The 
author  has  investigated  a  few  cases  of  high  unilateral  irregular  corneal 
astigmatism  evidently  due  to  the  same  cause. 

Tumors  and  Cysts  of  the  Cornea. — Tumors  of  the  cornea  are 
rare.  The  following  have  been  described :  fibroma,  papilloma,  myxoma, 
dermoids,  sarcoma,  epithehoma,  and  endothehoma.  True  fibromas 
have  been  reported,  but  usually  they  are  scar-fibromos,  that  is,  they 
are  hyperplastic  scars.  A  myxomatous  degeneration  of  such  a  scar  is 
the  probable  origin  of  the  so-called  corneal  myxomas.  The  papillomas, 
which  have  been  examined,  in  most  instances  have  arisen  at  the  hmbus 
and  invaded  the  cornea.  A  few  primary  sarcomas,  even  in  children, 
have  .been  described,  and  Parsons  has  investigated  one  endothehoma. 
According  to  this  authority,  nearly  all  of  the  cases  of  so-called  epithe- 
homa of  the  cornea  are  growths  beginning  in  the  limbus  at  the  position 


308 


DISEASES    OF    THE    CORNEA 


where  the  conjunctival  changes  into  corneal  epithehum.     This  was  the 
condition  of  aHairs  in  the  specimens  examined  by  the. author. 

Dermoid  tumor  is  a  congenital  growth,  and  sometimes  is  associated 
with  other  anomalies  of  the  lid  and  eyes.     Strictly  limited  to  the  cornea, 


Fig.  1.'J3. —  Dermoid  of  the  cornea 
(from  a  patient  in  the  Philadelphia  Gen- 
eral Hospital). 


Fig.  134. —  Dermoid  of  the  corneo- 
scleral junction,  which  on  section  showed 
a  gland  inclusion  (from  a  patient  iii  the 
University  Hospital). 


it  is  most  uncommon;  generally  it  occurs  as  a  firm,  hemispheric,  yel- 
lowish-white growth,  lying  partly  upon  the  cornea  and  partly  upon  the 
conjunctiva.  The  apex,  often  paler  than  the  rest  of  the  growth,  is 
covered  with  short  hairs.     These,  however,  occasionally  grow  to  an 


i^tf'> 


^- 


xKmim 


Vm.    l.i.j.  — .Mi(T08(!opic  section  of  dcrmoiil  of  corneoscleral  junction  with  jiland 

inclusion. 


unusual  Iciiglli,  and  have  liccn  scm  protiuding  through  the  lis.^^urc  of 
the  lids  and  hanging  down  upon  the  cheeks.  If  undisturbed,  the  tu- 
mor may  slowly  enlarge,  and  has  been  reported  to  have  adaincd  the 
size  ( f  a  walnut.     Bilateral  dermoids  have  been  recordeil. 


CONGENITAL    ANOMALIES    OF    THE    CORNEA  309 

These  dermoids  have  been  ascribed  by  Van  Duj^se  to  the  remains 
of  amniotic  adhesions,  and  by  Remak  to  invagination  of  the  ectoderm. 
Microscopically,  the  growth  represents  the  structure  of  the  skin  and  its 
appendages. 

Teratoid  tumors  may  be  situated  at  the  corneoscleral  junction, 
rareh',  if  ever,  on  the  cornea,  or  upon  the  outer  half  of  the  sclera,  or 
upon  the  bulbus  in  the  neighborhood  of  the  caruncle.  They  contain, 
as  a  rule,  acinotubular  glands,  fatty  tissue,  smooth  and  striated  muscle- 
fiber,  hyaUn  bodies,  and  catrilage. 

Corneal  cysts,  according  to  Oatman,  occur  in  two  principal  forms — 
epithelial  and  lymphatic.  The  first  varietj'  is  the  more  common;  it 
usually  arises  from  the  epithelial  layer  of  the  conjunctiva,  which  is 
ingrafted  on  the  cornea.  Cysts  following  injury  of  the  cornea  have 
been  ascribed  to  the  prohferation  of  surface  epithelium  which  has 
been  carried  into  the  corneal  stroma.  They  are,  therefore,  implantation 
cysts.  Oatman  doubted  this  pathogenesis,  and  explained  them  by 
assuming  that  a  proliferation  of  superficial  epithelium  lines  the  wound 
with  epithelial  cells,  and  the  mass  thus  produced,  separated  from  con- 
nections with  the  surface,  takes  on  an  active  growth  and  forms  the  cyst. 
True  lymphatic  retention  cysts  may  result  from  dilatation  of  the  corneal 
canals  and  spaces.  Corneal  cysts  may  be  cured  by  excising  a  piece  of 
their  walls. 

Congenital  Anomalies  of  the  Cornea. — Microphthalmos  is  that 
condition  in  which  the  entire  eye  remains  in  a  more  or  less  rudimentary 
state,  and  in  which  the  cornea  is  too  small  in  all  its  diameters.  Pure 
cases  of  microphthalmos,  according  to  Manz,  are  very  rare;  usually 
one  or  other  of  the  component  portions  of  the  globe  is  wanting.  Numer- 
ous theories  have  been  advanced  to  explain  their  etiology — in- 
complete closure  of  the  fetal  ocular  cleft  (Arlt),  fetal  illness  in  orhita 
(Wedl  and  Boch),  intra-uterine  sclerochorioretinitis  (Deutschmann). 
The  a'^ection  has  also  been  ascribed  to  the  influence  of  heredity. 

Megalophthabnos  has  been  described  on  page  426. 

Sclerophthalmia  or  sclerosis  is  that  condition  in  which  the  opacity  of 
the  sclerotic  encroaches  upon  the  cornea  in  such  a  manner  that  only  the 
central  portion  remains  transparent.  It  is  due  to  an  imperfect  differ- 
entiation of  the  cornea  and  sclera  at  an  early  period  of  fetal  life.  It  may 
be  symmetric,  and  a  "^ect  only  the  upper  half  of  the  cornea. 

Congenital  opacities  of  the  cornea  are  seen  in  the  form  of  milky  spots 
which  may  clear  up  in  later  life,  or  as  leukomas.  Usually  the  iris  is 
dimly  visible  through  the  clouded  tissue.  These  opacities  are  due  either 
to  intra-uterine  inflammation  or  to  an  arrest  of  development  (see  also 
Birth  Injuries,  page  307).  Embryotoxon  (arcus  juvenalis)  is  a  con- 
genital opacity  of  the  cornea  which  resembles  an  arcus  senilis. 

Congenital  anterior  staphyloma  of  the  cornea  appears  in  the  form  of 
a  true  staphyloma,  and  is  a  rare  affection.  The  abnormaUty  depends 
not  so  much  upon  a  malformation  or  an  arrest  of  development  as  upon 
a  fetal  inflammation,  which,  according  to  Pincus,  takes  place  in  the 
second  haff  of  fetal  life.     They  have  been  well  studied  by  J.  Herbert 


310 


DISEASES   OF   THE    CORNEA 


Parsons,  who  holds  that  the  lesions  develop  in  exactly  the  same  manner 
as  they  do  when  they  take  place  after  birth.  Treacher  Collins,  how- 
ever, thinks  failure  of  the  development  of  the  anterior  chamber  may  be 
the  original  cause  in  some  cases.  Peters  ascribes  the  condition  to  de- 
fective development  of  Descemet's  membrane,  and  E.  von  Hippel  to 
internal  ulcer  of  the  cornea  (see  also  page  280).  Heredity  probably 
plays  some  rolo  in  this  and  similar  affections  of  the  cornea.  Congenital 
staphyloma  of  the  cornea  associated  with  dermoid  formation  has  been 
reported. 

Congenital  melanosis  or  pigmentation  of  the  cornea  may  appear  in  the 
form  of  a  vertically  oval  area  of  brownish  color  in  the  center  of  this 
membrane.  The  affection  is  more  common  in  women  than  in  men. 
It  has  been  ascribed  to  an  abnormal  development  of  the  uveal  tract 
(Krukenberg).  The  lesion  has  been  well  studied  in  this  country  by 
Dr.  T.  B.  Holloway,  and  he  has  described  peripheral  pigmentation  of  the 
cornea  in  association  with  symptoms  suggesting  multiple  sclerosis; 
some  of  the  patients  have  cirrhosis  of  the  liver.  Congenital  famihal 
flatness  of  the  cornea  {cornea  plana),  according  to  Ruel,  is  characterized 
by  flattening  of  the  anterior  portion  of  the  eyeball  in  such  a  manner 
that  the  curvature  of  the  cornea  passes  directly  into  the  curve  of  the 
sclera  without  the  formation  of  an  angle.  In  Huel's  patients  the  cor- 
neas were  diffusely  opaque. 


CHAPTER  VIII 
DISEASES  OF  THE  SCLERA 

The  sclera,  constituting  four-fifths  of  the  covering  of  the  globe  of 
the  eye,  and  being  in  intimate  relationship  with  the  choroid  and  ciliary 
body,  is  subject  to  inflammations  peculiar  to  itself,  and  to  changes  in- 
dicative of  disease  of  these  subjacent  structures.  Its  close  connection 
with  the  cornea  associates  the  latter  membrane  in  some  phases  of  its 
diseases,  and  its  union  with  the  iris  through  the  pectinate  ligament 
establishes  an  anatomic  connection,  just  as  there  often  is  a  pathologic 
relation.  The  overlying  bulbar  conjunctiva  necessarily  participates  in 
scleral  inflammation. 

The  inflammations  affect  (1)  the  episcleral  tissue  (episcleritis)  and 
(2)  the  sclera  itself  (scleritis),  and  hence  are  superficial  or  deep.  They 
further  are  acute  or  chronic,  diffuse  or  circumscribed. 

Episcleritis  occurs  in  the  form  of  small,  dusky  red,  subconjunc- 
tival swellings  or  nodes,  which  usually  appear  in  the  ciliary  region  on 
the  temporal  side  of  the  cornea,  though  patches  may  occur  in  any  por- 
tion of  the  zone. 

The  conjunctival  vessels  over  the  patch  are  coarsely  injected,  and 
movable  with  the  somewhat  edematous  conjunctiva.  The  episcleral 
vessels  show  a  dusky  congestion  which  is  immovable.  The  elevation 
is  sometimes  tender  to  pressure  and  sometimes  not,  and  there  may  or 
may  not  be  much  ii-ritation  and  pain.  In  some  cases  of  phlyctenular 
disease  of  the  corneal  margin  it  is  difficult  to  decide  between  this 
affection  and  episcleritis;  what  appears  to  be  a  patch  of  the  latter  may 
develop  into  the  former. 

The  disease  runs  a  subacute  course,  reaching  its  height  in  about 
three  weeks,  then  gradually  disappears,  and  leaves  a  somewhat  dull 
area  of  discoloration  marking  its  former  position.  Relapses  are  fre- 
quent, both  at  the  original  seat  or  in  new  spots  on  the  sclera,  and  these 
recurrences  may  happen  again  and  again  for  months  and  even  years. 
The  cornea  and  uveal  tract  easily  participate  in  the  inflammation. 

Cause. — Episcleritis  and  episcleral  n.odes,  either  solid  or  moderately 
soft  in  texture,  are  more  frequent  in  women  than  in  men  in  the  author's 
experience.  Patches  of  episcleritis  of  the  character  described  occur  in 
the  eyes  of  those  who  are  much  exposed  to  the  weather.  In  other  cases 
superficial  scleritis  is  caused  by  rheumatism,  gout,  tuberculosis,  men- 
strual derangements,  enterogenous  auto-intoxication  and  focal  in- 
fections in  the  teeth  and  tonsils,  and  also  appears  without  discoverable 
cause.  Well-marked  episcleral  (not  conjunctival)  congestion  or 
episcleritis  occurs  in  connection  with  disease  of  the  accessory  sinuses, 
especially  the  ethmoids. 

311 


312  DISEASES    OF   THE    SCLERA 

III  these  forms  of  superficial  scleritis  the  prognosis  is  good  so  far  as 
sight  is  concerned,  because  deeper  and  adjacent  structures  are  unin- 
volvf'd.  but  unfavorable  on  account  of  the  recurrences. 

Treatment. — This  consists  in  the  use  of  atropin  to  allay  pain  and 
prevent  any  tendency  to  iritis,  warm  antiseptic  collyria,  and  hot  com- 
presses. Dionin  is  of  distinct  service.  In  the  chronic  tj'pes  eserin  and 
pilocarpin,  }i  to  3^^  grain  (0.0162-0.324  gm.)  to  the  ounce  (30  c.c.)  of 
water,  have  a  beneficial  influence,  provided  no  iritis  is  present.  Sub- 
conjunctival injections  of  salt  solution  are  useful,  antl  similar  injec- 
tions of  salicylate  of  sodium  (2  per  cent.)  and  of  hetol  (cinnamate  of 
sodium)  have  been  recommended  (Pfliigcr).  ^Massage  with  a  salve  of 
the  yellow  oxid  of  mercury  is  indicated  in  chronic  cases,  and  it  has 
been  recommended  to  scarify  the  tumefaction,  scrape  it  away  with  a 
sharp  curet,  or  cauterize  it  repeatedly,  in  a  superficial  manner,  with 
the  actual  cautery.  Internally,  salicylic  acid  and  iodid  of  potassium 
are  needed  in  rheumatic  cases,  and  good  results  follow  diaphoresis  with 
pilocarpin  or  the  Turkish  bath.  ]\Ienstrual  and  uterine  disorders  must 
be  rectified,  and  the  influence  of  intestinal  sepsis  eliminated  as  well  as 
any  areas  of  focal  infection.  If  a  tuberculous  taint  is  discovered, 
injections  of  tuberculin  are  of  service.  Any  error  of  refraction  or 
anomaly  of  the  exterior  eye  muscles  should  be  corrected. 

Fugacious  Periodic  Episcleritis. — This  name  has  recently  been 
applied  by  Fuchs  to  a  variety  of  relapsing  episcleritis  characterized  by 
the  appearance  of  one  or  more  patches  of  episcleral  injection  or  edema, 
of  violaceous  hue,  lasting  from  two  to  eight  days,  and  reappearing  again 
at  intervals  of  several  weeks  or  even  months,  to  go  through  the  same 
course.  The  duration  of  the  aTection  is  usually  about  one  year:  it 
occurs  most  frequently  in  adults.  Gout  and  rheumatism  are  asso- 
ciated constitutional  conditions.  The  same  affection  was  described 
some  years  ago  by  Swan  M.  Burnett  under  the  name  of  "Vasomotor 
Dilatation  of  the  Vessels,"  and  by  Jonathan  Hutchinson  with  the  title 
"Hot  Eye."  The  treatment  is  the  same  as  tliat  ahcndy  recommentied 
for  episcleritis. 

Scleritis  may  appear  in  the  form  of  a  diffuse,  biuish-reti  injection, 
occupying  the  entire  exposed  portion  of  the  sclera,  very  painful,  unat- 
tended with  secretion,  save  some  increase  in  lacrimation,  and  liable  to 
be  mistaken  for  conjunctivitis  or  iritis;  or  in  tiie  form  of  circumscribed 
patches,  of  violaceous  tint,  situated  in  the  ciliary  region,  and  somewhat 
ntsembiing  in  appearance  the  forms  of  superficial  or  episch'ral  eleva- 
tions just  described,  being,  however,  less  sharply  defined,  so  that  the 
whole  zoiK'  may  l)e  involved,  but  in  uruMiual  degree.  Spicer  calls  atten- 
tion to  cicsccntic  areas  of  infiltration  in  the  cornea,  separated  from  the 
patch  of  scl(»ral  inflanunation  by  a  band  of  clear  cornea.  In  many 
cases  of  di  fuse  deep  scleritis,  hard,  whitish  nodules  devc^lop  in  the  in- 
flamed tissue  {noduUir  scleritis).  Overgrowth  of  the  inliltrated  tissue 
may  pnjducc;  diffuse  or  cireuinscribed  areas,  which  are  calleil  lii/pcr- 
plustic  scleritis.  The  rUirf  distinction  between  the  suihrjicidl  ;iiul  ilccp 
forms   of   scler;il    iiiti.iiuiiiat  ion    is    the    almost    iii\  ariable   tt'iuieiicv   of 


SCLEEITIS 


313 


the  latter  to  affect  other  portions  of  the  eye — the  cornea  and  uveal 
tract. 

Pathology. — In  episcleritis  the  infiltrating  cells  are  found  either  in 
the  superficial  layers  around  the  conjunctival  vessels  or  in  the  deepest 
layers.  The  vessels  are  dilated,  extravasations  of  blood  are  found,  and 
often  spots  of  necrosis  and  giant  cells.  Usually  the  choroid  and  sclera 
are  infiltrated  and  edematous. 

The  causes  of  deep  scleritis  are  exposure  to  cold,  rheumatism, 
gout,  scrofula,  vasomotor  changes,  and  disturbances  of  the  sexual 
apparatus,  especially  anomalies  of  menstruation.  Young  adults  are 
most  frequently  attacked.  The  so-called  gummatous  scleritis,  in  which 
the  patches  are  yellowish  brown  and  translucent,  is  due  to  syphilis; 
and  gonorrhea,  if  it  is  associated 


with  synovitis,  may  cause  the 
disorder.  One  form  of  scleritis 
may  be  the  forerunner  of  paren- 
chymatous keratitis.  Deep  scle- 
ritis is  also  seen  in  the  subjects 
of  congenital  syphilis  and  tuber- 
culosis. The  trial  of  tuberculin 
in  scleritis  will  often  be  followed 
by  a  general  as  well  as  a  local 
reaction.  Excised  nodules  may 
show  epithelioid  cells  and  giant 
cells,  but  no  •  tubercle  bacilli. 
Tuberculous  scleritis  is  probably 
due  to  an  infection  derived  from 
the  aqueous  arising  from  the 
filtration  angle  (Verhoeff).  Fi- 
nally, types  of  scleritis  (scleroker- 
atitis)  unassociated  with  any 
definite  cause  or  diathesis  are 
seen  in  young  and  middle-aged 
subjects,  most  commonly  women, 
whose  nutrition  is  depressed,  and 
who  may  or  may  not  have  a  tuberculous  disposition  or  inheritance. 
Scleritis  may  be  a  metastatic  inflammation,  the  original  focus  of 
infection  being  at  some  distant  part  of  the  body,  for  example,  a  rectal 
abscess,  a  felon,  or  a  purulent  sinusitis  (Dupuy-Dutemps)  and  arise 
because  of  the  more  usual  focal  infections  in  the  teeth,  tonsils  and 
intestinal  tract.  Disturbances  of  the  internal  secretions  are  doubtless 
of  etiologic  influence  in  many  cases. 

Deep  scleritis  usually  attacks  both  eyes,  runs  a  chronic  course,  and 
may  e  ect  the  iris  (leading  to  closure  of  the  pupil),  ciliary  body, 
choroid,  vitreous  (causing  opacities),  and  the  cornea.  In  prolonged 
cases  of  the  disease  dark  scars  remain  after  absorption  of  the  products 
of  the  inflammation,  which  are  unable  to  resist  the  intra-ocular  pres- 
sure, and  form  elevations  {ectasia  sclera;).     Total  scleral  ectasia,  or  an 


Fig.  136. — Tuberculous  sclerokerStitis, 
showing  scleral  nodules  and  characteristic 
triangular  corneal  infiltration  (from  a  patient 
in  the  University  Hospital). 


314  DISEASES    OF   THE    SCLERA 

enlargement  of  all  the  diameters  of  the  globe,  is  seen  in  buphthalmos 
(page  426).  Sometimes  the  whole  anterior  portion  of  the  sclera  be- 
comes bluish  or  slaty  colored,  is  misshapen  and  elongated,  and  the 
cornea,  which  appears  small,  is  poorly  differentiated  from  it  on  ac- 
count of  the  haziness  of  its  margins. 

Sclerokerato=iritis  {Scrofulous  Scleriiis;  Anterior  Choroiditis). — 
This  name  is  applied  to  the  complicated  scleritis  referred  to  in  the  pre- 
vious paragraph,  and  is  characterized  by  chronicity,  relapses,  and 
involvement  of  the  cornea  and  iris. 

Beginning  with  a  deep  scleritis  of  the  ciliary  zone,  the  adjacent  cor- 
nea becomes  opaque  and  sometimes  ulcerates;  the  iris  is  inflamed,  pos- 
terior synechise  form,  and  pain  and  congestion  may  be  severe.  After 
weeks  the  symptoms  subside,  the  characteristic  discolored  area  marks 
the  former  scleral  disease,  and  haziness  in  the  cornea  indicates  the 
seat  of  previous  inflammation  in  this  membrane.  Relapse  takes 
place,  with  fresh  scleritis,  new  corneal  involvement,  renewed  iritis,  or 
iridochoroiditis,  and  vitreous  changes,  and  so  on,  until  after  many 
months,  it  may  be,  the  disease  comes  to  an  end,  leaving  the  sclera  discol- 
ored and  bulged,  the  cornea  covered  with  patch-like  opacities,  the  iris 
bound  down  with  adhesions,  the  vitreous  filled  with  opacities,  and  the 
eye  practically  deprived  of  vision. 

Sclerotizing  keratitis,  referred  to  on  page  297,  is  the  name  applied 
to  a  patch  of  opacity  in  the  deeper  corneal  layers,  usually  triangular  in 
shape,  with  its  b^se  toward  the  patch  of  scleritis,  which  is  its  origin. 
After  the  cure  of  the  scleritis,  a  white  or  yellowish-white  opacity  re- 
mains directly  in  contact  with  the  sclera.  Instead  of  a  single  patch  of 
this  character,  several  small  triangular  areas  may  arise  in  the  circum- 
ference of  the  cornea  as  the  result  of  scleritis. 

Treatment. — The  treatment  of  scleritis  and  sclerokerato-iritis  de- 
pends upon  the  type  and  stage  of  the  disease  and  the  presence  or  ab- 
sense  of  definite  cause.  The  elimination  of  the  areas  of  focal  infection 
(teeth,  tonsils,  etc.)  constitutes  an  important  part  of  the  treatment. 
Locally,  atropin,  hot  compresses,  holocain,  dionin,  and  boric  acid 
lotion,  and  in  painful  cases  leeches  to  the  temple  are  suitable.  Pilo- 
carpin  is  valuable  if  iritis  is  not  present.  The  eyes  should  be  carefully 
protected  with  goggles.  After  the  subsidence  of  acute  symptoms 
massage  may  be  tried.  The  use  of  th(>  actual  cautery  has  been  men- 
tioned.    Sulx'onjunctival  saline  injections  are  useful. 

In  rheumatic  cases  salol,  the  salicylates,  the  alkalis,  and  iodid  of 
potassium  are  the  most  available  remedies;  in  gout,  carefully  regulated 
diet,  mineral  waters. — Bui.alo,  Poland,  etc., — citrate  of  lithium,  and 
colchicuni,  especially  in  tlie  form  of  colchicin,  and  change  of  climate 
are  useful.  Cod-liver  oil,  iodin,  iron,  and  sweats  with  pilocarpin, 
3^10  gi'ain  (O.OUGlS  gm.)  hypodermically,  are  also  indicated.  The  dia- 
phoretic measures  are  proper  in  any  case,  other  things  being  equal,  and, 
in  place  of  pibx-arpin,  an  electric  cabinet  or  Turkish  bath  may  be  the 
means  of  crealiMg  diaphoresis.  In  syphilis,  bichlorid  of  mercury, 
inunctions    (»f    meicuiial  oinliiient ,   and   aisphi-naniin  are  efiicacious. 


STAPHYLOMA  OF  THE  SCLERA  315 

Indeed,  mercury  is  generally  advantageous  as  a  means  of  altering 
the  nutrition  of  the  part  and  preventing  exudation  into  the  uveal 
tract.  Disorders  of  menstruation  should  always  be  corrected.  Finally, 
in  subjects  with  depressed  nutrition,  quinin,  arsenic,  and  a  general 
tonic  regimen  are  required.  Because  many  cases  of  scleritis  are  due 
to  tuberculosis  a  tuberculin  treatment  (see  page  341)  is  often  indi- 
cated, and  may  be  followed  by  most  satisfactory  results.  Tests  with 
tuberculin  should  always  be  made;  a  positive  reaction  will  follow  in  a 
number  of  instances.  The  internal  administration  of  thyroid  extract  is 
indicated  in  some  cases. 

Annular  Scleritis  (Brawny  Infiltration  of  the  Sclera). — To  this 
severe  form  of  scleritis,  which  invariably  affects  the  whole  region 
around  the  cornea,  J.  Herbert  Parsons,  G.  Derby,  and  Verhoe  if  have 
called  renewed  attention.  Unlike  ordinary  scleritis,  which  usually 
attacks  young  adults,  this  affection  is  a  disease  of  advanced  age  or,  at 
least,  of  middle  life.  Both  eyes  are  usually  affected,  though  not  to  an 
equal  extent.  The  disease  is  essentially  chronic,  and  subject  to  peri- 
odic exacerbations  and  remissions.  Verhoeff  believes  that  syphilis  is  an 
important  etiologic  factor,  although  this  cause  is  doubted  bj^  Schodt- 
mann,  who  first  described  the  disease.  Gilbert  has  ascribed  it  to  gout. 
The  prognosis  is  most  unfavorable,  many  of  the  ej^es  having  been  lost. 
The  corneal  margin  is  the  essential  site  of  the  infiltration,  from  which 
region  it  spreads  on  both  sides  into  the  surrounding  tissues,  overlapping 
the  cornea  on  the  one  side  and  extending  as  far  as  the  equator  of  the 
eyeball  posteriorly  on  the  other.  The  swelling  is  usually  gelatinous 
and  succulent  and  has  a  brownish-red  color.  In  addition  to  the  in- 
volvement of  the  cornea,  the  uveal  tract,  especially  the  anterior  part 
of  the  choroid  and  the  ciliary  body,  are  inflamed. 

Posterior  Scleritis. — In  this  affection,  as  described  by  Fuchs,  the 
symptoms  are  edema  of  the  lid,  exophthalmos,  conjunctival  chemosis, 
and  ophthalmoscopically  the  appearance  of  detachment  of  the  retina, 
or  of  a  gray  cloudiness  over  the  affected  area.  After  the  subsidence  of 
the  inflammation  changes  in  the  retina  remain.  Secondary  iridocyclitis 
may  arise.  According  to  Coats,  the  disease  depends  upon  blocking  of 
one  of  the  larger  ciliary  arteries  and  consequent  infarction  of  the  inner 
layers  of  the  sclera,  choroid,  and  retina. 

Staphyloma  of  the  sclera  (Ectasia  of  the  Sclera)  has  been  divided 
by  systematic  writers  into  partial  and  total  ectasia  and  anterior, 
equatorial,  and  posterior  staphyloma,  according  to  the  situation  of  the 
lesion.  Posterior  staphjdoma  is  detected  with  the  ophthalmoscope  in 
a  highly  myopic  eye  (see  page  138)  and  consists  of  a  thinning  and 
bulging  of  the  sclera  usually  at  the  outer  side  of  the  optic  nerve  entrance 
(posterior  staphyloma  of  Scarpa).  In  association  with  coloboma  of 
the  choroid  (page  370)  below  the  posterior  pole  of  the  eye  there  may  be 
a  scleral  ectasia  (posterior  staphyloma  of  Amman). 

It  is  evident  that  all  bulging  of  the  sclera  depends  upon  a  distur- 
bance between  the  resistance  of  the  sclera  and  the  intra-ocular  tension, 
but  it  is  not  evident  in  all  cases  whether  the  process  which  originated 


316 


DISEASES    OF    THE    SCLERA 


the  trouble  began  in  the  underlying  tissue  or  in  the  scleral  structure  it- 
self. One  or  more  darkly  tinted  swellings  may  arise  in  the  ciliary 
region  and  sometimes  entirely'  surround  the  ej'eball  {ciliary  staphy- 
lotna)  or  in  the  region  in  front  of  the  ciliary  body,  that  is  between 
it  and  the  edge  of  the  cornea  (intercalary  staphyloma) ,  one  sometimes 
occurring  in  advance  of  each  rectus  tendon;  or,  finally,  the  staphyloma- 
tous  swellings  may  exist  at  the  equator  in  the  region  of  the  vena  vorti- 
cosa  and  are  not  noticeable  unless  the  eye  is  rotated  strongly  in  one 
direction  or  another.  A  general  enlargement  of  the  scleral  coat  is  seen, 
for  example,  in  hydrophthalmos  (page  426)  or  where  in  young  subjects  a 
combination  of  staphyloma  of  the  cornea  (page  280)  and  anterior 
scleral  staphj-loma  {total  ectasia)  exists. 

The  following  causes  may  originate  scleral  staphyloma:  Chronic 
glaucoma,  old  kerato-iritis  and  closure  of  the  pupil,  recurring  scleritis 
and  sclerokerato-iritis,  inflammation  of  the  ciliary  body,  thinning  of 
the  scleral  coat  by  repeated  attacks  of  inflammation,  tumors,  and 
wounds  closed  by  non-resisting  scars. 

Treatment. — A  single  scleral  staphyloma  may  not  destroy  vision. 
If  the  intra-ocular  tension  is  increased,  an  iridectomy  is  indicated. 
If  the  eye  is  useless,  enucleation  or  one  of  its  substitutes  may  be 
necessary. 

Abscess  and  ulcers  of  the  sclera  are  exceedingly  uncommon. 
Abscess  in  the  scleral  tissue  may  result  from  an  infected  wound  and 

has  been  seen  in  connection  with 
certain  specific  and  contagious  dis- 
eases— e.  g.,  glanders.  Metastatic 
scleral  infection  has  been  recorded 
(see  page  313). 

Ulcer  of  the  episcleral  tissue  has 
been  described  in  association  with 
tuberculosis.  A  tumor,  gumma,  or 
tubercle  of  another  region  of  the  eye 
may  break  down  and  ulccrat(^  into 
the  sclera. 

Tumors  of  the  sclera  are 
rare  growths.  The  following  have 
been  ilescribed:  ril>r()ma.  til)rochon- 
droina,  ('iichondroiua,  anil  osteoma. 
Primary  sarcoma,  if  it  exists, 
must  be  rare;  recently  a  case  has 
been  recorded;  secondary  sarcoma,  carcinoma,  and  glioma  have  been  re- 
ported, (lununa  of  tlie  sclera  has  l)cen  described,  and  tubercle  may 
invade  it  from  the  uveal  tract.  A  few  scleral  cysts  have  bi'en  ret'orded 
Ismail  piimary  scleral  growths  may  be  dissecteil  from  their  l)eds,  and 
the  wounds  closed  with  conjunctival  sutures  (Fig.  137). 

Injuries  of  the  Sclera. — Wounds  of  the  sclera  may  be  caused  by 
a  shar|»  implement  (knife,  scissors,  broken  glass,  etc.)  or  foreign  body 
(chip  of  iron  oi-  steel,  fragment  of  slnai)nel,  bullet,  etc.),  or  they  may 


^^^r^fj^^ff^^-^^ 


Fig.  137. — Cyst  of  the  corneoscleral  junc 
tion  (Philadelphia  General  Hospital). 


INJURIES    OF    THE    SCLERA  317 

result  from  a  blow  on  the  bulbus  on  the  inner  side  and  above,  more 
rarely  downward  and  out  (impact  of  a  flying  object,  e.  g.,  golf  ball, 
thrust  of  a  blunt  object,  e.  g.,  a  cow's  horn,  violent  contact  with  a 
stationary  object,  e.  g.,  edge  of  a  door),  causing  rupture  of  the  sclera 
which  is  usually  found  3  mm.  from,  and  concentric  with,  the  corneal  mar- 
gin (T.  Collins).  The  rupture  may  be  exposed  through  a  rent  in  the 
conjunctiva,  and  is  then  said  to  be  "compound,"  or  it  may  be  con- 
cealed by  the  conjunctiva,  which  is  untorn.  It  may  be  direct,  that  is 
rupture  takes  place  at  the  point  of  impact,  or  indirect,  that  is  the  rup- 
ture takes  place  at  some  point  other  than  at  the  point  of  impact. 
Indirect  ruptures  of  the  sclera  occur  in  the  vicinity  of  the  cornea  and 
are  more  or  less  concentric  with  it,  because  here,  due  to  the  presence  of 
Schlemm's  canal  and  the  penetrating  anterior  cihary  veins,  there  is  an 
area  of  poor  resistance.  A  blow  may  also  rupture  the  cornea.  Corneal 
tears,  according  to  L.  Miiller,  are  more  common  in  young  people  than 
scleral  ruptures.  Small  ruptures  at  the  limbus  or  within  the  corneal 
margin  are  usually  associated  with  iris  prolapse.  Incomplete  ruptures 
of  the  sclera  have  been  observed  (Fuchs)  made  manifest  by  a  bluish 
hue  near  the  limbus,  which  later  becomes  ectatic. 

If  the  wound  has  perforated  the  sclera,  two  complications  are  liable 
to  be  present:  loss  of  a  portion  of  the  contents  of  the  globe  and  injury 
to  the  inner  coats,  and  the  introduction  into  the  eye  of  septic  material 
which  will  cause  destructive  inflammation. 

Symptoms. — A  perforating  wound  of  the  sclera,  if  sufficiently  large, 
causes  loss  in  the  tension  of  the  globe,  hemorrhage  into  the  vitreous,  or, 
it  may  be,  into  the  anterior  chamber,  and  the  appearance  of  dark  tissue 
in  the  wound,  representing,  according  to  its  situation,  portions  of  the 
choroid  or  ciliary  body;  a  bead  of  vitreous  is  likely  to  present.  A 
small  perforating  scleral  wound  may  be  hidden  by  the  overlying  con- 
tused and  swollen  conjunctiva.  Usually  the  intra-ocular  tesion  is 
lower  than  normal.  It  must  be  remembered  that  although  hypotony 
is  a  symptom  of  penetrating  wound  or  rupture  of  the  sclera  it  may 
also  occur  as  the  result  of  contusion  of  the  globe  without  rupture; 
hypotony  does  not  prove  that  rupture  is  present.  Rupture  of  the 
sclera  is  commonly  associated  with  grave  lesions  in  other  portions  of 
the  eye — separation  of  the  retina,  tears  in  the  choroid  and  iris  and  dis- 
location or  expulsion  of  the  lens.  To  the  extensive  disorganization  of 
the  eyeball,  with  large  wounds  or  ruptures  of  the  sclera  so  often  ob- 
served during  the  past  war  the  term  "shattered  eye"  was  often 
apphed. 

Prognosis. — This  depends  upon  (1)  the  extent  and  situation  of  the 
wound  and  amount  of  escape  of  vitreous;  (2)  the  presence  or  absence 
of  septic  material  upon  the  implement  or  body  which  inflicted  the 
injury;  (3)  whether  a  foreign  body  has  remained  within  the  globe;  and 
(4)  the  character  of  the  foreign  body  which  may  have  entered.  It  is 
evident  that  even  a  trifling  perforating  wound,  unattended  with  loss  of 
vitreous  or  prolapse  of  the  inner  coats,  may  be  a  point  of  entrance  of 
infection. 


318  DISEASES    OF   THE    SCLERA 

Treatment. — Having  carefully  ascertained  that  no  foreign  body  is 
within  the  globe,  the  eye  should  be  disinfected  with  a  solution  of  bi- 
chlorid  of  mercury  (1  :  5000),  and  the  edges  of  the  wound,  after  all  foreign 
substances  have  been  removed,  penciled  with  a  stronger  solution  of  the 
same  drug  (1  :  2000)  or  with  a  5  per  cent,  solution  of  iodin.  The  over- 
lying conjunctiva  is  next  drawn  together  with  several  fine  sutures. 
The  eye  is  closed  with  an  antiseptic  compressing  bandage  and  the 
patient  is  put  to  bed.  Iced  compresses  are  an  advantage  during  the 
early  stages  of  the  treatment.  At  the  end  of  forty-eight  hours  the 
wound  may  be  inspected  and  the  dressings  renewed.  In  larger  wounds 
the  sutures  (sterile  silk  or  catgut)  are  passed  directly  through  the 
sclera  by  some  surgeons,  care  being  taken  to  avoid  the  choroid,  but  the 
author  agrees  with  Snell  that  usually  scleral  sutures  are  not  necessary, 
conjunctival  sutures  being  sufficient;  the  sutures  may  be  removed  at 
the  end  of  a  week  if  the  healing  has  progressed  favorably.  Some 
surgeons  advise  the  introduction  of  iodoform  before  the  application 
of  the  bandage.  In  some  instances,  in  spite  of  kind  healing  of  the 
scleral  wound,  there  are  subsequent  detachment  of  the  retina,  vitreous 
change,  and  shrinking  of  the  eyeball,  but  occasionally  apparently 
hopelessly  injured  eyes  may  be  saved  by  careful  conservative  aseptic 
surgery.  As  tetanus,  especially  after  earth  contamination,  may  follow 
penetrating  wounds  of  the  eye  antitetanic  serum  should  be  administered. 

In  the  event  of  a  scleral  wound  being  extensive,  with  much  loss  of 
vitreous  and  collapse  of  the  coats,  especially  if  the  cihary  bodj'-  is 
involved  and  sight  practically  gone,  or  if  the  endeavors  to  remove  the 
foreign  body  have  been  unsuccessful,  enucleation  should  be  performed 
to  avoid  the  dangers  of  sympathetic  inflammation  in  the  fellow  eye. 

Foreign  Bodies.^ — If  the  wounding  substance  has  been  small — 
e.  g.,  a  chip  of  steel,  a  splinter  of  glass,  a  particle  of  tlynamite  cap, 
fragment  of  schrapnel  or  a  bullet — endeavor  should  be  made  to  ascertain 
whether  this  has  penetrated  the  globe  and  remained  within  it,  or  has 
passed  entirely  through  the  eyeball  and  buried  itself  in  the  tissues  of 
the  orbit.  Foreign  bodies  maj^  be  emb(Hld<^d  in  any  of  the  structures 
of  the  eye  and  are  frequently  found  in  the  vitreous.  If  loose,  they 
tend  to  gravitate  to  the  lowest  part  of  the  vitreous  and  rest  upon  the 
posterior  part  of  the  ciliary  body  (T.  Collins). 

Double  perforation  of  the  oyi'  is  not  uncommon  as  the  result  of  a 
bullet  wound  or  one  caused  by  the  explosion  of  a  dynamite  cap,  but 
less  frequent  if  the  foreign  body  is  a  chip  of  iron  or  steel.  In  rare 
instances  the  perforation  of  the  posterior  scleral  wall  has  been  iliscov- 
ered  with  tiie  oijhthalnioscope,  but  since  the  introduction  of  .r-ray 
examination  tlic  diagnosis  is  rend(»red  comparatively  ejusy,  aiul  the 
radiographs  should  show  whether  the  foreign  boily  luus  piu^sed  entirely 
through  the  posterior  scleral  wall  or  is  enib(>(id(Mi  partly  witliin  and 
partly  without  the  scleral  covering. 

'It  is  convenient  to  discuss  in  this  place  the  treatment  of /oreif^M  IkkUcs  whioli 
are  IocIkccI  in  the  vitreous  or  any  of  the  inl<*rnal  ocuhir  coats  after  haviiip;  p»>nt'- 
tratcil  the  sclera  covering. 


FOREIGN   BODIES  319 

According  to  Leber,  perforating  injuries  of  the  eye  with  pieces  of 
copper  msiy  result  in  purulent  inflammation  merely  by  the  chemic 
action  of  the  metal;  if  infection  is  absent,  an  attempt  to  remove  the 
body  may  be  made,  and,  if  successful,  the  eye  saved,  even  if  inflam- 
mation has  begun. 

Foreign  bodies  may  be  tolerated  for  long  periods  of  time,  with 
good  vision,  in  the  background  of  the  eye,  but  can  never  be  trusted 
especially  if  located  in  the  uveal  tract ;  they  are  liable  to  cause  degenerative 
changes.  However,  small  fragments  of  glass  have  remained  for  years 
within  the  globe  without  creating  untoward  symptoms  and  the  lens  is 
more  tolerant  of  foreign  bodies  than  the  other  internal  ocular  tissues. 
Sometimes  foreign  bodies  are  embedded  in  the  external  scleral  walls;  if 
anteriorly  placed  they  are  readily  removed  with  a  magnet  if  thej'  are 
either  iron  or  steel. 

Unfortunately,  blood  in  the  vitreous  and  anterior  chamber,  or 
opacity  of  the  lens,  is  apt  to  obscure  the  media  to  such  a  degree  that 
ophthalmoscopic  examination  is  not  of  much  service;  but  if  the  media 
are  clear,  this  method  may  be  the  means  of  detecting  the  foreign  body. 
Air  bubbles  in  the  vitreous  are  suggestive,  but  not  pathognomonic  of  a 
foreign  body  in  the  globe.  An  attempt  at  locating  the  body  may  be 
made  bj'  observing  the  situation  of  the  wound,  the  condition  of  the 
capsule  of  the  lens,  the  probable  direction  which  the  foreign  substance 
took  on  making  its  entrance,  bj'  a  search  for  points  of  tenderness  and 
for  a  scotoma  in  the  field  of  vision.  If  there  is  any  doubt,  a  skiagraphic 
examination  should  be  undertaken,  and  in  the  majority  of  instances 
pieces  of  wood  excepted)  the  Rontgen  rays  ■VN'ill  readily  reveal  the 
presence  and  position  of  the  foreign  body.  Of  the  various  methods 
devised  for  this  purpose,  the  one  elaborated  bj-  W.  IM.  Sweet,  in  the 
opinion  of  the  author,  is  most  satisfactory.  The  method  of  McKenzie 
Davidson  and  Dixon's  modification  of  the  Sweet  method  are  also 
excellent. 

Having  satisfied  himself  of  the  presence  and  position  of  a  non- 
7netallic  foreign  body  within  the  globe,  the  surgeon  may  attempt  to 
extract  it  through  the  original  wound  with  dehcate,  carefully  disin- 
fected forceps,  or  through  a  new  wound  made  in  the  most  favorable 
situation,  guided  if  possible  by  simultaneous  ophthalmoscopic  exami- 
nation. But  in  some  instances  a  small  fragment  of  sterile  glass,  for 
example,  difficult  or  almost  impossible  to  reach  had  better  be  allowed 
to  remain  rather  than  to  make  matters  worse  by  the  frequent  introduc- 
tion of  instruments  into  the  vitreous  chamber  in  the  effort  to  extract  it. 
During  the  past  war  a  few  non-metallic  foreign  bodies  were  located  by 
a  specially  devised  fluoroscope  and  extracted  through  a  scleral  incision, 
but  such  fortunate  operative  results  were  rare. 

If  the  foreign  body  is  composed  of  iron  or  steel  and  its  presence 
cannot  be  detected  on  account  of  opacities  in  the  media,  a  diagnosis 
may  be  made,  as  was  first  suggested  by  T.  R.  Pooley,  with  the  magnetic 
needle.  Useful  instruments  have  been  constructed  on  this  principle 
by  Asmus  and  Hirschberg,  and  are  known  as  sideroscopes,  with  which 


320 


DISEASES    OF   THE    SCLERA 


a  properly  protected  magnetic  needle  is  brought  near  different  portions 
of  the  eye  in  succession,  and  any  deviation  of  the  needle  carefully 
noted.  Where  the  deviation  is  greatest  there  is  reason  to  suspect  the 
foreign  body  exists. 

A  large  magnet  may  also  be  employed  for  diagnostic  purposes,  the 
dislodgnient  of  the  foreign  particle  giving  rise  to  a  localized  spot  of 
pain  or  point  of  bulging,  but  great  care  must  be  exercised  in  attempt- 
ing this  procedure,  as  sudden  movement  of  the  foreign  body  may 
cause  serious  intra-ocular  lesions,  hemorrhage,  tearing  of  the  iris,  etc. 
Moreover,  as  has  been  pointed  out  by  Hirschberg,  the  absence  of  pain 
when  the  eye  is  approached  by  the  magnet  docs  not  surely  exclude  the 
presence  of  a  foreign  body. 


Fig.    13S. — Foreinn  l)o«iy  in  the  vitreous. 


The  most  satisfactoiv  luclhod  in  a  (l()ul)tl'ul  case,  and  wlicit'  the 
media  are  so  obscured  that  ophthalinoscopic  cNaMiiiiation  is  impossible, 
is  the  employment  of  the  .c-rays,  which,  if  propi-rly  used  according  to 
Sweet's  method  (see  Appendix,  page  768),  have,  in  the  author's  expe- 
rience, never  failed  to  give  exact  information  of  the  position  of  the 
foreign  substance.  When  this  has  been  detcrmineil.  the  boily  should 
be  extracted  with  the  electromagnet.  In  former  times  it  was  nuich 
the  practice  to  introtluce  tlii;  extension  point  of  a  magnet,  for  example, 
the  Hirschberg  model,  either  through  the  original  entrance-wound  or 
through  one  made  U)v  that  purpose,  as  far  into  the  vitreous  as  was  neces- 
sary to  attract  the  S|)lint('r  of  iron  or  steel  from  its  position.  This 
iiielliod  has  been  al)andoned  for  otlieis  which  are  much  more  satis- 


FOREIGN   BODIES  321 

factory  in  that  the  introduction  of  an  instrument  into  the  vitreous 
is  avoided.  The  magnets  most  in  use  are  giant  magnets  (Haab's 
model  and  its  modifications — an  instrument  unsurpassed  in  excellence ; 
Volkmann's  model;  Hirschberg's  model);  the  Innenpol  77iagnet  de- 
signed by  Mellinger,  the  patient's  head,  bring  placed  within  a 
large  electric  coil,  while  the  passage  of  the  current  magnetizes  both  the 
foreign  bodj^  in  the  eye  and  the  iron  instrument  held  in  front  of  the  eye 
to  attract  it;  and,  large  or  sling-magnets  of  which  those  designed  by 
Sweet,  Parker,  Lancaster  and  Lister  are  types. 

Whether  intra-ocular  metallic  foreign  bodies  shaU  be  removed  along 
the  anterior  or  posterior  route  must  be  settled  by  the  surgeon  in  charge 
of  the  case.  The  author  is  in  favor  of  the  posterior  route  after  x-ray 
localization  of  the  fragment,  save  only  where  there  is  a  large,  fresh 
wound  of  entrance  and  a  body  of  considerable  size,  and  in  the  case  of 
very  small  bodies  in  the  forward  regions  of  the  eye.  Points  of  im- 
portance are  that  the  operation  shall  be  done  as  soon  as  possible  after 
the  accident,  that  not  infrequently  small  foreign  bodies  penetrate  and 
leave  no  external  evidence  of  the  point  of  entrance — hence  the  impor- 
tance of  x-ray  examination  of  any  eye  which  has  been  exposed  to  the 
possibility  of  such  an  accident.  The  wound  of  entrance,  or  one  made 
during  the  operation  of  extraction  of  the  foreign  body,  must  be  care- 
fully covered  with  a  conjunctival  flap  (see  Conjunctivoplasty). 

There  are  three  routes  along  which  the  foreign  body  may  be  at- 
tracted by  the  magnet:  (a)  Through  the  wound  of  entrance,  advisable 
if  the  body  is  of  large  size;  ih)  from  the  regions  posterior  to  the  plane 
of  the  iris,  i.  e.,  the  ciliary  bod}',  lens,  vitreous  chamber  (the  usual 
situation),  choroid  or  retina,  into  the  anterior  chamber,  the  so-called 
anterior  route;  (c)  through  a  small  opening  made  in  the  sclera,  its  posi- 
tion being  determined  as  the  one  nearest  to  the  situation  of  the  foreign 
body  by  means  of  a'-ray  localization,  the  so-called  scleral  or  posterior 
route. 

During  the  past  war  x-ray  examination  often  was  not  possible  or  the 
delay  entailed  was  not  deemed  advisable.  Haab  strongly  condemns 
the  extraction  of  steel  or  iron  from  the  interior  of  the  eye  through  a 
scleral  incision,  and  his  opinion  in  this  respect  is  shared  by  many 
surgeons,  and  Parsons  has  advanced  reasons  from  the  pathologic  stand- 
point in  opposition  to  scleral  route.  Charles  Goulden  examined  the 
records  of  118  extractions  of  metallic  foreign  bodies  from  the  eye,  and 
found  that  the  worst  ultimate  results  occurred  if  the  body  entered 
through  the  sclera  or  if  it  was  removed  by  scleral  puncture.  The 
author's  preference  has  been  stated.  For  methods  of  operating  and 
a  further  discussion  of  this  subject  see  pages  716,  717. 

If  infection  has  already  begun  when  the  patient  is  seen,  and  the 
condition  of  the  eye  is  not  so  hopeless  that  immediate  enucleation 
is  necessary,  various  methods  have  been  tried  to  check  the  purulent 
process.  If,  for  example,  the  wound  of  entrance  has  been  through  the 
cornea,  and  the  anterior  chamber  contains  pus,  this  may  be  evacuated, 
and,  as  Haab  recommends,  small  rods  of  sterilized  iodoform,  one  or  two, 

21 


322  DISEASES    OF   THE    SCLERA 

according  to  circumstances,  may  be  introduced  within  this  chamber. 
He  also,  in  like  manner,  introduces  these  rods  directly  into  the  vitre- 
ous if  infection  has  be^un  in  that  region,  and  reports  successes.  This 
method  of  intra-ocular  disinfection  has  been  sharply  criticised — Krause, 
for  example,  believing  that  iodoform,  either  in  the  form  of  powder  or 
rods,  is  unable  to  influence  favorably  beginning  infection,  but  that,  on 
the  contrary,  of  itself  it  may  produce  pathologic  changes,  and  repre- 
sents a  method  inferior  to  other  well-known  procedures  for  the  relief 
of  infected  wounds — for  example,  that  of  Schirmer,  who  brings  the 
patient  under  the  influence  of  mercury  by  inunctions.  The  author 
has  tried  the  iodoform  method  in  several  cases  with  indifferent  success, 
and  prefers  the  use  of  mercury,  especially  calomel,  in  repeated,  properly 
guarded,  doses.  Drainage  of  the  anterior  chamber,  expression  of  the 
lens,  and  thorough  irrigation  of  the  posterior  chamber  with  salt  solution 
have  seemed  to  be  of  service  in  a  few  cases  in  the  author's  practice. 
Constant  iced  compresses  are  of  value.  Van  Millingen  has  suggested 
the  trial  of  endocular  cauterization  in  these  circumstances — that  is, 
the  introduction  into  an  infected  scleral  wound  of  a  galvanocautery 
point,  if  necessary,  even  into  the  vitreous,  and  the  cauterization  of  all 
surrounding  tissue. 

Prognosis. — This  is  always  grave,  but  by  means  of  the  methods 
just  detailed  many  eyes  have  been  saved,  and  some  with  useful  vision. 
The  important  point  is  to  operate  as  soon  as  possible  after  the  accident 
— i.  e.,  before  the  foreign  substance  has  become  incarcerated  in  the 
tissues  and  covered  with  Ij^mph.  Coppez  and  Gunsberg  maintain  that 
the  prognosis  is  more  favorable  with  those  bodies  which  are  situat<Hl 
in  the  vitreous  than  with  those  entangled  in  the  ciliary  bodj'  or 
choroid.  Goulden's  results  have  been  referred  to  (see  page  321).  If 
judicious  efforts  have  failed  to  extract  a  foreign  body  from  the  interior 
of  the  eye,  or  if  infection  has  proceeded  beyond  the  reasonable  hope  of 
recovery,  enucleation  or  evisceration  usually  is  necessary. 

If  a  particle  of  iron  remains  for  some  time  in  the  eye,  there  is  a 
deposit  of  iron  pigment  in  its  tissues  which  gives  rise  to  a  condition 
known  as  siderosis  bulhi,  characterized  by  a  peculiar  greenish-yellow  or 
yellowish-brown  discoloration  of  the  iris  and  cornea,  and  a  circle  of 
brown  dots  beneath  the  capsule  of  the  lens.  The  pigmentation  may  be 
due  to  the  iron  derived  from  the  foreign  body  (xenogenous  pigmenta- 
tion) or  to  hemosiderin  derived  from  blood  (hematogenous  pigmenta- 
tion). Sometimes  the  iris  regains  its  original  color  after  removal 
of  the  foreign  body  and,  occasionally,  even  if  it  remains  within 
the  eye. 

Congenital  pigmentation  of  the  sclera  (melanosis  sclera;)  occurs 
both  in  spots  and  as  a  more  diffuse  discoloration.  The  spots  are 
more  common  in  the  iipi)er  portion,  and  may  be  associated  with 
pigrn(>nt  changes  in  the  iris  and  choroid.  PignuMit  spots  inthesclcMa 
have  been  observed  in  certain  di.seases — c.  g.,  Adilison's  liisease  —and 
sometimes  are  exactly  symmetric,  situated  near  the  margin  of  tiie 
cornea. 


BLUE    SCLEKAS  323 

Blue  scleras  may  be  associated  with  inherited  syphiHs  and 
exhibit  a  remarkable  hereditary  transmission.  In  addition  to  the 
leaden  color  of  the  sclera,  there  may  be  conical  cornea  and  congenital 
opacity  of  the  cornea,  that  is,  embryotoxon.  Harman  traced  in  five 
generations  of  one  family  55  members,  of  whom  31  showed  this  con- 
genital peculiarity.  Transmission  occurs  through  affected  mothers. 
Persons  with  blue  scleras  are  peculiarly  liable  to  bony  fractures. 


CHAPTER  IX 
DISEASES   OF   THE  IRIS 

Congenital    Anomalies. — Heterochromia,    or    the    condition    in 

which  the  color  of  one  iris  is  different  from  that  of  the  other,  is  a  pecu- 
Harity  which  may  be  without  pathologic  significance,  but  in  many  in- 
stances the  signs  of  cyclitis  in  the  lighter  colored  eye  are  evident,  and 
this  eye  is  liable  to  cataract  formation  (see  page  53). 

Corectopia,  a  term  applied  to  an  eccentric  position  of  the  pupil,  is 
not  to  be  confounded  with  cases  of  true  coloboma  of  the  iris,  presently 
to  be  described.  The  grade  of  corectopia  may  vary  from  a  slight  in- 
crease of  the  normal  eccentric  position  of  the  jnipil  below  and  to  the  in- 
ner side,  to  those  cases  in  which  the  whole  pupil  is  displaced  toward  the 
border  of  the  cornea.  The  latter  variety  is  a  very  unusual  phenome- 
non. This  complete  shifting  of  the  normal  position  of  the  pupil  has 
been  ascribed  either  to  an  essential  malformation  or  to  the  n^sult  of  a 
fetal  iritis.  Both  eyes  may  be  affected  symmetrically,  and  several 
members  of  the  same  family  may  present  the  defect. 


Fig.    i;i',).      P(jlycoria.  Fig.    140. — Persistent  pupillary  inoinbraiie:   (1)  Pupil 

contracted;  (2)  pujiil  dilated  (W'ickerkiewica). 

Pohjcoria,  or  a  multij^licily  of  i)upils.  is  a  rare  anomaly.  The  ab- 
normal pupil  or  pupils  may  be  situated  in  the  innnediate  neighborlutod 
of  the  normal  pupil,  separated  from  one  another  by  a  narrow  band  of 
iris  tissue,  or  the  increased  number  of  pu])ils  may  be  the  result  of  cross- 
ing strands  of  persisting  i)upillarv  membrane  (Fig.  139,  see  also  page 
330).  An  opening  which  exists  at  the  ciliary  margin  t)f  tht>  iris  has 
been  describetl,  and  is  probably  due  to  a  coiiiji  niUil  iridodidlysis. 

Persistent  pupillary  membrane  results  from  an  incomplete  resolution 
of  the  membrane  which  covers  the  anterior  surface  of  the  lens  during 
fetal  life,  and  which  usually  disappears  in  the  sev(Mith  month.  Mltluuigh 
it  may  remain  as  late  as  the  end  of  intra-iitnine  lil"e,  and  i'\(ii  in  the 
first  month  after  biith. 

Accurately  speaking,  the  |iii|)illar\  nicniliiane  is  a  specialized  por- 
tion of  the  ctipsKhiiniiillldry  covering.  The  name  of  pii|)illary  mem- 
brane alone  is  applicable  to  those  ca.'^es  in  which  threads  attached  to  the 
324 


CONGENITAL   ANOMALIES 


325 


small  circle  of  the  iris  pass  diametrically  or  cord-wise  across  the  pupil, 
to  be  inserted  elsewhere  in  the  corona  (Fig.  140).  Usually  the  fibers 
proceed  from  the  anterior  surface  of  the  iris  across  the  pupil,  either 
singly  or  in  groups  of  three  or  more  strands.  Sometimes  the  fibers 
remain  separated;  sometimes  they  grow  together  in  front  of  the  ante- 
rior capsule  or  unite  in  the  form  of  a  variously  colored  plaque,  adherent 
to  the  capsule  of  the  lens  (capsulopupillary  membrane) .  Persistent  pu- 
pillary membrane  is  more  common  in  one  than  in  both  ej^es;  of  68 
cases  observed  by  Stephenson,  13  %vere  bilateral  and  55  unilateral. 

Capsulopupillary  tags  are  not  infrequently  mistaken  for  the  syn- 
echia due  to  iritis;  indeed,  the  association  of  the  two  has  been  observed. 
No  difficulty,  however,  should  arise,  because  the  normal  action  of  the 
pupil  is  not  impeded  by  the  presence  of  these  vestigial  anomalies.  The 
appearance  is  not  often  detected  until  some  other  disorder  calls  for  an 
ophthalmoscopic  examination,  because  vision  is  not  seriously  or  at  all 


^^firj-r^0\'^ 


'^"'^CififX^^'^' 


Fig.   141. — Bilateral  coloboma  of  iris,  upward  and  outward,  and  cataract  (University 

Hospital). 

impaired.  Oblique  illumination  or  examination  with  a  loupe  or  corneal 
microscope  will  readily  demonstrate  the  remainsof  pupillary  membrane. 

Coloboma  of  the  iris  is  a  fissure  of  this  membrane  which  in  a  general 
way  resembles  an  artificial  pupil  made  by  iridectomy.  The  anomaly 
is  more  frequent  in  both  eyes  than  in  a  single  eye.  Where  the  defect  is 
unilateral,  the  anomaly  is  usually  found  on  the  left  side.  The  situation 
of  the  fissure  is  generally  downward  or  downward  and  inward.  Excep- 
tions to  this  rule  have  been  observed;  indeed,  numerous  atypical  forms 
have  been  recorded,  the  defect  being  placed  outward,  inward,  upward, 
down-and-out,  up-and-in,  and  up-and-out. 

The  coloboma  may  extend  across  the  whole  iris  {complete  coloboma) , 
or  stop  at  a  certain  distance  from  the  ciliary  margin  {incomplete  colo- 
boma). In  addition,  the  so-called  pseudocoloboma  is  described,  which 
may  be  looked  upon  as  a  form  of  heterochromia  of  the  iris,  or  indicates 
the  last  remains  of  the  ocular  fissure  which  is  tending  toward  closure, 
and  which  appears  as  a  small  stripe,  somewhat  granular,  and  differen- 
tiated from  the  rest  of  the  iris  by  its  brighter  color.  In  "bridge  colo- 
boma" the  borders  of  the  cleft  are  united  by  a  narrow  pigmented  or 
colorless  band  of  fibers. 


326  DISEASES    OF   THE    IRIS 

Coloboma  of  the  iris,  often  hereditary,  is  frequentlj'  associated 
with  similar  defects  in  the  choroid,  and  also  with  microphthalmos, 
congenital  cataract,  fissure  of  the  eyelids,  hps,  and  palate.  It  has 
been  attributed  to  an  arrest  of  development,  the  result  of  incomplete 
closure  of  the  choroidal  fissure;  but  Lang  and  Treacher  Collins  believe 
that  the  defect  is  caused  by  a  partial  abnormal  adhesion  or  late  sepa- 
ration of  the  lens  and  cornea,  the  iris  faiUng  to  develop  in  that  portion 
of  the  area  which  is  involved.  If  the  abnormal  adhesion  or  late  sepa- 
ration is  complete,  irideremia  results. 

Irideremia,  or  congenital  absence  of  the  iris,  occurs  both  in  a  partial 
and  a  complete  form. 

Total  congenital  irideremia  is  almost  invariably  bilateral.  It  is 
frequently  associated  with  other  anomalies  of  the  globe — partial  or 
complete  cataract,  dislocation  of  the  lens,  nystagmus,  strabismus,  de- 
partures from  the  normal  curvature  of  the  cornea,  or  annular  opacities 
in  its  periphery  and  atroph}'  of  the  optic  nerve.  In  a  majority  of  in- 
stances there  is  a  marked  hereditary  tendency. 

Congenital  ectropion  of  the  uvea,  consists  in  a  round  mass  of  dark 
color  projecting  from  the  margin  of  the  pupil,  bending  around  to  the 
anterior  border  of  the  iris.  A  similar  formation  is  proper  to  the  eye 
of  the  horse  and  is  frequently  seen  in  the  cow.  This  appearance  has 
sometimes  been  described  as  a  papilloma  of  the  iris;  it  is  not,  however, 
a  neoplasm,  but  a  congenital  ectropion  of  the  uvea. 

Cysts,  nevi,  and  atrophies  of  the  iris  occur  as  congenital  defects,  and 
congenital  aplasia  of  the  anterior  layers  of  the  iris  has  been  observed. 

Hyperemia  of  the  iris  is  associated  with  several  acute  affections 
of  the  eye,  for  example,  trachoma,  purulent  conjunctivitis,  kera- 
titis, scleritis,  inflammations  of  the  uveal  tract,  and  traumas,  and  is  a 
precursor  of  inflammation.  Hence  it  is  a  symptom  and  not  a  disease 
of  the  iris. 

Hyperemia  of  the  iris  is  recognized  by  change  in  color,  a  blue  iris 
becoming  greenish;  a  brown  iris,  a  reddish  brown;  by  contraction  of  the 
pupil,  which  dilates  sluggishly  or  not  at  all,  to  the  changes  of  shade  and 
light,  and  is  slowly  affected  by  a  "mydriatic,  the  etlects  of  which  are 
much  less  permanent  than  in  the  healthy  iris;  and  by  slight  pericorneal 
injection. 

The  treatment  consists  in  the  management  of  tlie  disease  which  has 
caused  the  hyperemia,  and  especiallj'  in  the  instillation  of  atropin. 

Iritis. — Under  the  general  term  iritis  are  included  various  types 
of  inlhunmation  of  the  iris. 

Causes. — Iritis  may  depend  upon  constitutional  ilisorders,  infec- 
ti(jns,  toxins,  antl  traumatism,  or  upon  (Usease  in  other  portions  of  the 
eye.  Hence,  it  is  usually  stated  that  iritis  is  either  primary  or  second- 
ary. In  point  of  fact,  however,  it  is  iloubtful  if  the  term  "primary 
iritis"  should  be  retained,  inasmuch  as  iritis  is  probably  nev(>r  primary, 
but  always  sc'condary,  in  that  it  is  one  of  the  manif(>stations  of  the 
action  of  a  toxin  or  an  infection.  To  those  cases  of  iiitis  which  np- 
parently  originate  indcpcndctitly  of  injury,  or  of  an  oculiir  or  constitu- 


IRITIS  327 

tional  disorder,  the  name  idiopathic  was  formerly  applied,  a  term  which 
should  be  eliminated,  although,  unfortunately,  we  are  unable  always 
to  decide  what  exactly  is  the  causative  factor  in  each  case.  Iritis 
is  also  divided,  according  to  its  supposed  etiology,  into  syphilitic, 
rheumatic,  gouty,  gonorrheal,  diabetic,  tuberculous,  scrofulous,  septic, 
autotoxemic  or  toxemic,  cachectic,  traumatic,  and  sympathetic  iritis. 

Symptoms. — 1.  Change  in  the  color  of  the  iris,  in  addition  to  loss  of 
its  natural  luster  and  obscuration  of  the  characteristic  striated  appear- 
ance 

2.  Pericorneal  injection,  due  to  congestion  of  the  non-perforating 
branches  of  the  ciliary  vessels  (System  II) ,  producing  the  fine  pink  zone 
surrounding  the  cornea  known  as  "ciliarj^  congestion,"  or  the  "cir- 
cumcorneal  zone."  In  severe  cases  there  may  be  distention  of  the 
posterior  conjunctival  vessels,  and  slight  chemosis  of  the  conjunctiva 
(see  also  page  49) . 


Fig.  142. — -Various  forms  of  posterior  sj'nechiae:  A,  Single  attachment;  B,  multiple 
attachment  forming  the  so-called  "  ace-of-clubs "  pupil;  C,  irregular  annular  attachments 
(Sichel). 

3.  Miosis,  or  contraction  of  the  pupil,  due  partly  to  hyperemia  and 
spasm  of  the  sphincter,  and  partly  to  irritation  of  the  peripheral  nerve 
filaments.  The  reaction  of  the  pupil  to  the  influence  of  light  and  myd- 
riatics is  diminished  or  lost.  In  a  certain  number  of  cases,  according  to 
Herbert,  there  is  slight  dilatation  of  the  pupil  as  compared  with  the  un- 
affected eye.  This  primary  dilatation  of  the  pupil,  with  preservation 
of  its  reaction,  is  a  noteworthly  sympton  in  so-called  rheumatic  iritis 
(Kriickmann;  see  also  page  336). 

4.  The  formation  of  posterior  synechice,  or  attachments  between  the 
layer  of  pigment  covering  the  posterior  surface  of  the  iris  and  the  cap- 
sule of  the  lens.  They  are  demonstrable  by  the  instillation  of  a  myd- 
riatic, which  will  produce  an  irregular  dilatation  of  the  pupil,  certain 
portions  of  the  pupillary  margin  of  the  iris  being  held  back  by  some- 
what tongue-shaped  projections  attached  to  the  lens-capsule,  and  may 
be  readily  studied  by  means  of  obhque  illumination  or  with  a  loupe. 
The  tags  protruding  into  the  pupil  space  usually  have  a  brownish,  some- 
times'^a  grayish,  color. 

The  attachments  maj''  vary  in  size,  firmness,  and  number;  being 
either  narrow  and  thread-like,  broad  and  dense,  single  or  multiple,  or 
even  extending  all  around  and  pinning  down  the  margin  of  the  iris  in 


328  DISEASES    OF    THE    IKIS 

an  annular  mannor  {annular  posterior  synechia').  In  association  with 
the  synechiiE  there  may  be  an  exudation  of  false  nieniljrane  covering  the 
whole  pupillary  space  (pu])illarij  membrane  or  exudation). 

5.  Irregularities  in  the  surface  of  the  iris,  due  to  local  swellings,  accu- 
mulations of  exudation,  deposits  of  fibrin,  or  the  formation  of  nodules. 

6.  Haziness  of  the  cornea  or  deposits  upon  its  posterior  surface. 
According  to  Friedenwald,  the  cornea  is  affected  in  every  case  of  iritis, 
that  is,  there  are  deposits  on  Desceniet's  nienil)rant'  or  infiltrations  in 
the  substantia  propria.     The  former  are  constant,  the  latter  occasional. 

7.  Changes  in  the  character  of  the  aqueous  humor — (1)  Slight  or  con- 
siderable turbidity;  (2)  pus;  (.3)  blood;  and  (4)  occasionally  exudation. 

In  addition  to  the  symptoms  just  detailed  there  are  subjective  signs 
more  or  less  pecidiar  to  iritis. 

1.  Pain. — This  is  situated  first  in  the  eyeball,  and  is  known  as 
"ciliary  pain,"  and  second,  in  the  brow  and  temple,  sometimes  quite 
sharply  defined  in  the  distribution  of  the  supra-orbital  nerve,  very 
severe.  tlu-ob])iiig,  and  stabl)ing  in  character,  and  with  marked  increase 
in  severity  during  the  night.  Occasionally  the  nasal  and  infra-orbital 
regions  are  the  painful  areas.     Pain  in  the  teeth  is  not  unconunon. 

2.  Disturba7ice  of  Vision. — This  is  in  direct  proportion  to  the 
amount  of  cloudiness  which  has  occurred  in  the  media.  Decided  im- 
pairment of  visual  acuteness  denotes  extension  of  the  disease  to  the 
ciliary  body  or  deeper  structures. 

During  iritis,  transient  inyopia  and  astigmatism  are  commonly 
present.  Especially  in  the  plastic  types  of  the  disease,  even  after  full 
pupillary  dilatation,  an  increase  in  the  refractive  power  is  demonstrable. 
Although  there  arc  changes  in  the  corneal  curvature  the  bulk  of  the 
ametropie  change  in  such  cases  is  due  to  perversion  of  the  lens  action 
from  spastic  accommodation  (Roller)  as  the  result  of  ciliary  iritation. 
M*  3.  Tenderness  of  the  Globe. — This  is  often  present  in  uncomplicated 
iritis,  but  if  severe,  it  suggests  inflammation  of  the  ciliary  l)ody. 

4.  Photophobia  and  Lacrimation. — These  symptoms  vary  consider- 
ably in  degree,  being  almost  or  quite  absent  in  some  varieties,  and 
severe  in  those  of  acute  and  violiMit  onset. 

5.  Malaise,  fever,  nausea,  and  marked  depression  occasionally  are 
experienced  by  the  patient,  the  last  often  being  the  result  of  prolonged 
pain  and  insomnia. 

Diagnosis. — The  salient  symptoms  of  iiitis  just  det ailed  are  sutii- 
cient  for  the  purpose  of  tliagnosis;  nevertheli'ss,  it  is  nt)t  uni't)nun()n  to 
find  a  case  of  iritis  mistaken  for  some  otliei-  external  inllanmiation, 
and  the  table  on  i)age  320  may  be  found  useful.  In  the  earliest  stages 
of  iritis,  before  definite  signs  are  in  evidenci'  and  there  are  only 
hyi)cremia  and  iris  cramp,  the  diagnosis  is  at  times  diflicult.  Honui- 
tropin  solution  (2  per  cent.)  may  be  used  to  test  the  reaction  of  the 
iris  to  its  inliuence  or  <'uphthalmin  and  cocain  combined,  which  even 
if  glaucoma  llncalened  would  be  permissible  as  their  elTecIs  could  be 
readily   neutiali/ed  with  a  myotic. 

A  dilTuse  scleritis  somewhat  ii'sembles  in  its  color  the  /one  of  peri- 


IRITIS 


329 


corneal  injection  more  or  less  characteristic  of  iritis,  which,  indeed,  may 
be  a  complicating  symptom  of  the  disease.  Acute  glaucoma  bears  some 
resemblance  to  acute  iritis  (for  the  distinguishing  points  see  page  417. 


Ibitis. 

1.  Severe    brow 
worse  at  night. 

2.  Dim  vision. 


pain, 


3.  Fine  pericorneal  in- 
jection. 

4.  Absence  of  secre- 
tion; some  abnormal  lacri- 
mation. 

5.  Sluggish  or  immobile 
pupil. 

6.  Iris  discolored. 

7.  Abnormal  reaction 
to  mydriatic. 

8.  Severe  photophobia 
exceptional. 

9.  Conjunctiva  usually 
translucent;  occasionally 
chemotic. 

10.  Tenderness  on  pres- 
sure. 

11.  Posterior  svnechise. 


Simple  Conjunctivitis. 

Feeling  of  foreign  bodj- 
in  the  eye. 

Vision  usually  unim- 
paired, unless  secretion  is 
very  abundant. 

Coarse  conjunctival  in- 
jection. 

Mucopurulent  dis- 
charge; flakes  of  lymph. 

Pupil  unaffected. 

Iris  unchanged  in  color. 

Normal  reaction  to 
mydriatic. 

Severe  photophobia  ab- 
sent in  simple  cases. 

Conjunctiva  opaque, 
velvety,  and  at  times 
chemotic. 

Tenderness   not 
marked. 
Xo  svnechiae. 


Phltcten'ular 
CoNjuNcrn'iTis. 

Acute  general  irrita- 
tion. 

Vision  impaired  by  cor- 
neal involvement. 

Diffuse  injection,  with 
special  hues  of  vessels 
running  to  phlyctenules. 

Free  lacrimation. 


Pupil  unaffected. 

Iris  unchanged  in  color. 

Normal  reaction  to 
mydriatic. 

Severe  pho  tophobia 
and  blepharospasm. 

Conjunctiva  translu- 
cent, bathed  in  tears. 


Tenderness 
marked. 
No  svnechise. 


not 


Course,  Complications,  and  Prognosis. — An  iritis  may  pursue  an 
acute  course,  reaching  its  termination  in  four  to  eight  weeks,  or  be 
chronic  from  its  onset  and  last,  in  a  slow  and  insidious  inflammation, 
for  long  periods  of  time.  The  termination  of  an  iritis  may  be  entirely 
favorable.  The  inflammatory  adhesions  disappear,  and  the  iris  regains 
complete  mobility,  only  a  few  traces  of  iris  pigment  being  seen  on  the 
capsule  of  the  lens.  On  the  other  hand,  more  or  less  complete  attach- 
ment causing  distortion  and  inequahty  of  the  pupil  (consult  Fig.  142) 
may  remain;  or  deposits  of  exudation  may  directly  occlude  the  pupil 
and  He  upon  the  capsule  of  the  lens;  or  the  tissue  of  the  iris  may  show 
areas  of  atrophy  and  exhibit  a  bleached  or  grayish  aspect. 

The  binding  down  of  the  iris  throughout  the  whole  extent  of  its 
pupillary  edge,  although  the  pupil  itself  remains  clear,  is  denominated 
exclusion  or  seclusion  of  the  pupil;  if  the  pupil  is  filled  in  with  opaque 
inflammatory  deposit,  the  term  occlusion  of  the  pupil  is  applied.  With 
extensive  or  annular  synechise  the  angle  of  the  anterior  chamber  be- 
comes obliterated,  the  iris,  owing  to  the  exudation  behind  it,  is  bulged 
forward  except  around  its  pupillary  margin,  which  is  bound  down,  so 
that  a  crater-hke  depression  is  evident,  and  the  appearance  denom- 
inated iris  hornbe  is  developed.  This  leads  to  increased  tension,  second- 
ary glaucoma,  and  even  shrinking  of  the  vitreous,  detachment  of  the 
retina,  and  atrophy  of  the  eyeball  unless  the  communication  between  the 


330 


DISEASES    OF   THE    IRIS 


anterior  and  posterior  chambers  of  the  eye  is  restored  b}' operative  meas- 
ures (Figs.  143  and  144).  Repeated  attacks  of  iritis,  as  well  as  chronic 
inflammation  of  the  iris,  may  cause  atrophy  of  the  tistme.  In  these  cir- 
cumstances the  color  of  the  iris  is  gray,  the  markings  of  its  surface 
disappear,  dilated  blood-vessels  and  reddish  patches  appear,  small  holes 
develop  in  its  tissues,  the  pujjil  margin  is  thin,  and  its  tissue  is  friable 
(Fig.  143).     A  form  of  progressive  essential  atrophy  of  all  layers  of  the 


Fig.  143. — Exclusion  and  occlusion  of  pupil 
with  exudation  behind  iris,  following  gummatous 
iritis;  compare  with  Fig.  144  (from  a  patient  in 
the  Philadelphia  General  Hospital). 


Fig.   145. — Atrophy  of  iris  (from  patient  in  the 
University  Hospital). 


Fig.  144. — Exclusion  and  occlu- 
sion of  the  pupil.  The  iris  is  adher- 
ent by  its  entire  pupillary  margin'to 
the  lens.  Tiie  posterior  chamber|(^) 
is  thus  made  deeper,  the  anterior 
chamber  (r)  shallower,  especially 
where  the  root  of  the  iris  (a)  is 
pressed  against  the  cornea.  The 
retinal  pigment  is  beginning  to  sepa- 
rate at  s.  'I'he  pupil  is  cU>8ed  by  an 
exudate  menil)rane,  o.  In  tlie  lower 
part  of  the  anterior  chamber  there  is 
matter  (p)  precipitated  upon  the 
posterior  surface  of  the  cornea.  The 
cortex  of  the  lens  lias  become  cata- 
ractous  (r);  the  nucleus  (A)  is  un- 
altered (Fuchs). 


iris  has  been  described  (C.  A.  Wood,  Harms.  ZcntuKiyer,  Larsson,  and 
the  author),  Periods  of  increased  intra-ocular  tension  are  eviii(>nt  and 
the  eyes  become  glaucomatous.  Wood  did  not  consiiliM-  that  glaucoma 
was  an  essential  part  of  the  affection,  although  it  waa  the  end  process 
in  his  i)atient.  The  anatomic  examination  rev(>aletl,  in  addition  to 
glaucoma  and  iris  atrophy,  a  librinoplaslic  cyclitis. 


IRITIS    AND    ITS    TYPES  331 

The  following  tissues  of  the  eyes  may  become  involved  during  the 
course  of  an  iritis:  The  cornea  {keratitis  punctata);  the  ciliary  body 
(iridocyclitis);  the  crystalline  lens  {cataract  especially  cataracta  accretd, 
in  which  the  iris  and  lens  are  fastened  together) ;  the  choroid  {irido- 
choroiditis) ;  the  vitreous  {exudation  into  the  vitreous,  hyalitis) ;  and  the 
optic  nerve  and  retina  {hyperemia,  retinitis,  optic  neuritis).  With  these 
facts  in  mind,  and  •^dth  the  tendency  of  certain  types  of  the  disease  to 
relapse  a  prognosis  must  he  guarded,  but  in  uncomphcated  iritis,  seen 
early  and  properly-  treated,  a  perfect  result  may  be  obtained  in  the 
large  majoritj-  of  cases.  Relapses  of  iritis  are  often  attributed  to 
posterior  synechise,  but,  as  Fuchs  points  out,  are  not  due  to  them,  but 
to  the  continuance  of  the  cause  of  the  affection. 

Pathology. — Systematic  writers  at  one  time  were  accustomed  to 
divide  iritis  into  three  varieties:  plastic,  parenchymatous,  and  serous 
iritis.  A  more  accurate  classification  from  the  pathologic  standpoint 
is  acute,  chronic,  purulent,  and  nodular  iritis.  In  general  terms,  in  iritis 
it  may  be  said  that  the  iris  is  thickened  and  infiltrated  with  round  cells, 
which  are  collected  either  along  the  line  of  the  vessels  or  in  circum- 
scribed nodules.  The  vessel  walls  are  thickened  and  small  hemorrhages 
occur  in  the  tissue.  The  exudation  in  the  anterior  chamber  consists  of 
round  cells,  mixed  with  fibrin  and  pigment  granules.  In  many  cases 
the  inflammatory  products  are  completely  absorbed,  but  should  they 
become  abundant,  they  organize,  forming  a  layer  of  connective  tissue 
which  covers  the  iris  and  binds  it  to  the  lens,  occluding  the  pupil  in  the 
manner  already  described.  The  exudation  in  the  iris  likewise  organizes, 
and  the  atrophic  iris  shows  obliterated  and  thickened  vessels,  clumping 
of  pigment  granules,  and  an  entire  absence  of  iris-stroma.  Purulent 
iritis  due  to  infection  with  micro-organisms  is  followed  by  panophthal- 
mitis. This  infection  may  come  from  without,  as  it  occurs,  for  example, 
in  perforating  injuries,  and  is  called  exogenous  injection;  or  from  within, 
as,  for  example,  in  metastatic  processes,  and  is  called  endogenous  infec- 
tion. In  nodular  iritis  the  nodes  are  formed  of  aggregations  of  lympho- 
cytes. It  is  often  difficult  to  distinguish  between  the  varieties  of  iritis 
from  the  histologic  standpoint,  as  they  merge  one  into  the  other.  If 
the  exudation  is  poor  in  cells  and  fibrin,  and  the  iris  tissue  shows  cellular 
infiltration,  there  is  serous  iritis  (not  to  be  confounded  with  the  cyclitis 
clinicall}'  called  serous  iritis) ;  if  the  exudation  is  rich  in  fibrin  but  poor 
in  cells,  and  the  iris  tissue  markedly  infiltrated,  there  is  fibrinous  iritis; 
if  with  an  exudation  rich  in  cells  and  fibrin  there  is  extensive  infiltration 
of  the  iris  tissue,  with  mononuclear  and  multinuclear  leukocytes,  there 
is  purulent  iritis  (Ginsberg). 

Treatment. — The  description  of  the  treatment  is  reserved  for  the 
subsequent  sections  devoted  to  the  particular  consideration  of  the 
various  tj^pes  of  iritis  which  follow. 

Iritis  and  Its  Types. — In  the  acute  form  of  the  disease  the  salient 
symptoms  of  iritis  already  recorded  (see  page  327)  are  present.  Not 
only  may  the  ordinary  attachments  form  between  the  iris  and  the  cap- 
sule of  the  lens,  but  a  plastic  exudation  may  cover  the  pupil-space  with 


332  DISEASES    OF   THE    IRIS 

a  false  membrane,  and  the  adhesions  between  the  iris  and  the  lens- 
capsule  may  be  unusually  firm  and  unyielding.  To  this  form  of  iritis 
the  descriptive  term  plastic  is  somethnes  applied.  In  some  cases  a 
gelatin-like  mass  is  deposited  in  the  anterior  chamber,  and  its  appear- 
ance has  been  compared  to  that  of  a  dislocated  lens  in  the  same  posi- 
tion {fibrinous  or  spongy  iritis  (see  also  page  741).  Sometimes  if 
synechiiE  are  elaborate  the  intra-ocular  tension  in  iritis  or  iridocyclitis 
(page  355)  may  rise  and  may  be  associated  with  increased  haze  in  the 
cornea,  but  haziness  of  the  cornea,  often  present  (page  328)  is  not  of 
itself  proof  that  ocular  pressure  is  increased.  In  various  forms  iritis 
is  seen  in — 

1.  Syphilis — Syphilitic  Iritis. — The  percentage  of  patients  with 
syphilis  who  acquire  iritis  during  the  course  of  the  disease  varies  from 
0.42  to  5.37,  according  to  the  different  authorities,  but  among  cases  of 
iritis,  syphilis  has  been  found  to  be  the  cause  in  from  30  to  60  per  cent. 
(Alexander).  Groenouw  among  2020  patients  with  syphilitic  ocular 
disorders  found  the  percentage  of  iritis  to  be  44.7.  Iritis  develops 
not  only  in  untreated  syphilitic  subjects,  but  also  in  those  who  are  under 
treatment  and  occasionally  has  arisen  after  an  injection  of  salvarsan 
(" Iridorezidive"  Ternlink,  quoted  bj'  Igersheimer).  Trauma  of  the 
eye,  a  blow  for  example,  may,  in  the  syphilitic  individual  be  the  exciting 
cause  of  an  iritis  (Igersheimer).  In  other  words,  syphilis  is  usually 
regarded  as  the  most  common  cause  of  iritis.  It  may  appear  between 
the  second  and  the  ninth  month  after  the  initial  lesion,  or  may  be 
delayed  until  the  eighteenth  month.  Occasionally  it  arises  at  a  very 
late  period  in  syphilis — that  is  to  say,  during  the  period  of  so-called 
tertiary  manifestations,  either  as  a  primary  iritis,  as  a  relapse,  or  in  one 
of  the  forms  presently  to  be  described.  The  lesions  are  due  to  the 
influence  of  syphilitic  virus,  that  is,  to  the  lodgment  and  activities  of 
the  Spirochseta  pallida,  which  has  been  found  in  the  aqueous  humor  of 
an  eye  with  acute  syphilitic  iritis  (Zur  Nedden,  Stephenson). 

The  clinical  manifestations  of  syphiUtic  iritis  vary.  They  may  he 
those  of  ordinary  acute  iritis  with  lesions  which  of  themselves  do 
not  justify  the  diagnosis  of  syphilis,  and  syphilis  as  the  etiologic 
factor  can  be  established  only  by  the  history  of  the  case,  by  the 
therapeutic  test,  or  by  the  serum  reaction  of  Wasserinaiin.  Acconl- 
ing  to  Kriickmann,  an  early  manifestation  of  syphilis  in  the  iris, 
which  may  appear  in  the  sixth  week  after  prinuiry  infection,  is  roseola, 
characterizetl  l)y  overfilling  of  suiierficially  ])laced  vessel  loops,  which 
arise  and  (lisai)pear  ([uickly.  The  color  is  bright  reil  in  contrast 
to  the  coi)))('r  tint  of  Ihc  skin  nuptioii.  Roseola  iua>'  in  later  stages 
be  the  forerunner  of  pajjules. 

Localized  si)hincter  lesions  alu.ays  suggest  the  inthuMiee  of  syphilis, 
and  with  the  development  of  pa|)ules  a  form  of  iiitis  appears  which 
yields  charactteristic,  it"  not  ])athognomonie.  signs  of  its  origin.  In  th(» 
inflamed  iris  there  a])pear  one  or  more  yellowish,  reddish-yellow,  or 
reddish-brown  nodules,  N-arying  in  size  from  ;i  hemp-seed  to  a  small  jjca, 
situated  at    the  ])upillary  or  ciliary  bonier,  oi-  occasionally  between 


IRITIS    AND    ITS    TYPES 


333 


the  two  in  the  iris  tissue,  although  Fuchs  maintains  that  they  do  not 
arise  in  the  midbreadth  of  the  iris.  They  vary  in  number  from  one 
to  four,  the  intervening  tissue  being  comparatively  unaffected,  and 
belong,  in  spite  of  their  resemblance  to  gummas,  with  which  at  one 
time  they  were  confused,  to  a  comparatively  early  period  of  syphihs — 
that  is,  to  the  period  indicated  in  the  previous  paragraph.  Under  the 
influence  of  treatment  they  are  gradually  absorbed  without  leaving 
very  marked  scars,  although  a  certain  amount  of  atrophy  of  the  iris  tis- 
sue on  close  examination  will  be  found  marking  their  former  situation. 
This  form  of  iritis  is  sometimes  called  true  syphilitic  iritis  or  syphilitic 
parenchymatous  iritis.  It  is  also  known  under  the  terms  iritis  papu- 
losa, or  condylomatosa.^  These  names  have  originated  because  the 
small  nodules  in  the  iris  have  been  compared  to  papular  syphilids  and 
condylomata,  inasmuch  as  they  belong  in  the  same  stage  of  syphilis 
with  these  manifestations.  They  clearlj-  differentiate  themselves  from 
gumma,  not  only  by  the  date  of  their  appearance,  but  because  they  do 
not  caseate  or  break  down  and  suppurate. 


Fig.  146. — Papules  in  syphilitic  iritis 
(from  a  patient  in  the  Philadelphia  Gen- 
eral Hospital). 


Fig.  147. — True  syphilitic  iritis  with 
large  nodes  in  iris;  about  seventh  month 
of  the  disease  (patient  in  the  University 
Hospital) . 


Even  where  these  distinct  nodules  are  not  present  in  syphilitic  iritis, 
careful  examination  of  the  iris  will  frequently  show  localized  discolored 
swellings  in  the  edematous  iris  tissue,  and  usually  broad  and  thick 
synechias,  formed  by  a  union  of  the  iris  tissue  with  lens-capsule,  and 
not  merely  an  adhesion  of  the  posterior  epitheHum,  and,  as  Fuchs 
has  shown,  microscopic  investigation  indicates  that  these  nodules 
are  always  present,  but  are  sometimes  so  small  that  they  have  not 
sufficiently^  elevated  the  iris  tissue  to  reveal  their  presence  to  ordin- 
ary clinical  methods  of  examination.  To  this  form  of  iritis  the  name 
syphilitic  or  luetic  fibrinous  iritis  is  sometimes  given. 

The  disposition  and  character  of  the  papules  which  develop  on  the 
iris  as  the  result  of  syphilis  have  been  particularly  studied  by  Kriick- 
mann,  who  among  the  early  varieties  describes  superficial  and  deep- 

^  Kriickmann  objects  to  the  term  "iritis  condylomatosa"  because  there  is  no 
accurate  comparison  to  be  made  between  condyloma  of  the  skin  and  the  papules 
of  the  iris  in  syphilis. 


334  DISEASES    OF   THE    IRIS 

seated  small  iris-syphilids,  the  chief  situation  of  the  latter  being  in  the 
vessels  system  of  the  sphincter  and  its  ininiodiato  noip;hborhood.  and 
medium-sized  papules  which  develop  under  the  anterior  stroma  layer. 
The  papules  of  an  early  stage  of  syphilis  often  have  a  reddish  color, 
while  those  of  later  periods  of  the  disease  are  yellow  or  grayish  yellow 
and  more  decidedly  circumscribed,  owing  to  the  absence  of  edema.  A 
rare  manifestation  is  the  eruption  of  the  papules  in  a  group  formation. 

Gummatous  iritis  or,  more  properly',  gumma  of  the  iris  occurs,  ap- 
pearing, according  to  Alexander,  almost  constantly  at  the  ciliary  bor- 
der. The  lesion  is  solitary,  of  the  size  of  a  pea  or  small  nut.  and  grows 
toward  the  ciliary  bod}',  disappearing  through  fatty  degeneration 
leaving  behind  a  permanent  scar,  or  atrophy  of  the  iris.  Such  a  mani- 
festation, strictly  localized  in  the  iris,  is  extremely  rare.  It  appears,  if 
at  all,  in  the  so-called  tertiary  period  of  sj'philis,  or  that  period  in  which 
gummas  in  other  organs  are  found. 

In  syphilitic  iritis  both  eyes  are  attacked,  one  a  little  later  than  its 
fellow;  occasionally  the  onset  is  simultaneous.  The  course  usually  is 
acute,  and  after  thorough  cure  relapses  are  not  common.  Sometimes 
the  disease  assumes  a  subacute  tyx)e,  or  may  be  so  prolonged  in  its 
course  and  complications  as  to  justify  the  term  chronic  iritis. 

Acute  iritis  of  the  so-called  plastic  type  is  rare  in  newborn  infants 
of  syphilitic  heritage,  but  has  been  described  in  children  with  inherited 
syphilis,  from  the  second  to  the  fifteenth  month.  Acute  iritis  in  chil- 
dren in  the  first  months  of  life,  and  also  in  later  childhood  years,  usu- 
ally is  the  result  of  hereditary  syphilis.  A  late  manifestation  appears 
in  the  form  of  an  iridocyclitis  of  the  so-called  serous  type,  the  involve- 
ment of  the  entire  uveal  tract  being  evident  by  the  manifestations  of 
the  signs  of  uveitis,  which  are  elsewhere  described. 

Treatment. — The  most  important  local  drug  in  this  as  in  other 
forms  of  iritis  is  atropin  sulphate,  gr.  iv  to  f5j  (0.2()  gm.  to  30  c.c), 
several  drops  of  the  solution  to  be  instilled  in  the  conjunctival  culdesac 
every  three  or  four  hours.  Mydriasis  should  be  maintained  until  all 
ciliary  irritation  has  subsided  and  during  the  ]KM-i<)d  of  changes  in  the 
refractive  power  of  the  eye  (see  jiago  328). 

Pain  is  relieved  and  at  the  same  time  congestion  is  diminisheil, 
thus  rendering  the  mydriatic  action  of  the  atropin  more  certain,  by 
leeching  the  temple — one  to  three  Swedish  leeches  being  api)lied  near 
the  line  of  the  hair,  or  blood  is  drawn  by  an  artificial  leech.  In  the 
absence  of  a  regular  heurtelouj),  this  may  be  aci'omijlished  i)y  making 
an  incision  in  the  temi)le  with  a  scaljiel  and  using  a  small  cui)ping-gla.><s, 
to  which  a  j)iston  is  attached  for  exhausting  fh(>  air.  Should  Mti<)i)in 
not  be  tolerated,  hyoscyamin,  scoi)olamin.  or  <liil)()isiM  may  be  substi- 
tuted (see  page  123). 

The  constant  use  of  atropin  leads  to  disagrccaltlc  dryness  of  (he 
throat.  This  may  be  obviated  in  part  by  compn^ssing  the  tear-duct 
after  each  application.  It  may  be  reliev(>d  by  giving  the  j)atient  a  gar- 
gle made  of  ('(pial  parts  of  icetl  water  and  a  strong  decoction  of  cofTee. 

Pain  is  furtlici-  rcli('\-(Ml  by  the  a[)])licatioii  of  moist  or  dry  heat :  the 


IRITIS    AND    ITS    TYPES  335 

latter  is  best  made  by  means  of  cotton  batting  which  is  held  before  a 
fire  and  then  laid  upon  the  affected  eye,  to  be  replaced  by  a  freshly 
heated  mass  as  soon  as  cooling  occurs,  or  with  a  Japanese  stove  or  hot 
box.  Moist  hot  applications  are  more  efficient  if  a  pad  of  surgical 
gauze  is  steeped  in  the  following  solution:  Acetate  of  lead,  5  j  (3.9  gm.) ; 
powdered  opium,  5ss  (15.5  gm.);  boiling  water,  Oj  (473.11  c.c.) 
(Randolph).  Dionin  in  5  to  10  per  cent,  solution  is  valuable  on  ac- 
count of  its  lymphagogue  and  analgesic  action,  which  is  increased  by 
the  addition  of  a  2  per  cent,  solution  of  holocain.  W-'ith  the  use  of 
high-frequency  currents  for  the  relief  of  the  pain  of  iritis  the  author 
has  had  no  experience. 

The  best  constitutional  treatment  is  some  form  of  mercury,  either 
the  protiodid,  blue  mass,  or  calomel,  given,  as  in  syphilis  generally, 
just  short  of  the  point  of  salivation,  and  continued  for  many  weeks  even 
after  all  acute  symptoms  have  subsided.  Inunctions  of  unguentum 
hydrargyrum  are  advantageously  employed,  preceded  by  a  hot  bath  or 
diaphoresis  with  the  aid  of  a  hot  chamber.  If  inunctions  are  properly 
given  they  represent  a  most  satisfactory  method  of  administering 
mercury,  and  usually  5  j  (3.9  gm.)  of  the  ointment  may  be  daily  rubbed 
into  the  skin.  Hypodermic  or,  rather,  intramuscular  injections  of 
mercury,  particularly^  mercuric  chlorid  or  salicjdate  of  mercury  (of 
mercuric  chlorid  the  dose  may  be  from  3^^ e  to  Jg  grain — 0.00405-0.008 
gm.;  of  salicylate  of  mercury,  3^^  grain — 0.0324  gm.),  are  strongly 
advocated  by  some  surgeons. 

In  syphilitic  iritis  salvarsan  produces  the  most  favorable  results, 
and  under  its  influence  the  lesions  disappear  with  astonishing  rapidity. 
If  the  Wassermann  test  is  positive,  other  things  being  equal,  a  dose  of 
0.6  gram  should  be  given  intravenously  (in  women  0.4  gram  is  usually 
sufficient).  At  the  expiration  of  three  weeks,  the  Wassermann  test 
being  still  positive,  this  dose  may  be  repeated.  During  the  intervals 
mercury  or  iodid  of  potassium  should  be  administered. 

Clinical  trial  of  neosalvarsan  indicates  that  it  equals  salvarsan  in 
efficiency  and  that  it  is  less  toxic.  In  arsenic  content  0.6  gram  of  sal- 
varsan is  equivalent  to  0.9  gram  of  neosalvarsan.  The  injections  may 
be  given  at  comparatively  frequent  intervals,  the  dose  being  regulated 
according  to  circumstances  and  effects,  as  often  as  once  in  ten  days  or 
two  weeks.  At  the  present  time  in  this  country  arsphenamin  and 
neoarsphenamin  are  used  in  place  of  the  formerly  employed  salvarsan 
and  neosalvarsan.  While  the  American  and  German  products  are 
practically  equivalent  in  so  far  as  their  dosage  is  concerned,  B.  A. 
Thomas  suggests  the  treatment  should  begin  in  the  adult  female  with 
0.4  grams,  and  in  the  adult  male  with  0.5  gram  of  arsphenamin, 
which  if  well  tolerated,  may  after  one  or  two  injections  be  increased  to 
0.6  gram.  If  neoarsphenamin  is  selected  the  first  dose  for  a  female 
should  be  0.6  gram  and  for  a  male  0.75  gram  to  be  increased  as  before 
to  0.9  gram. 

In  old  syphilitics  with  much  cachexia,  in  whom  a  plastic  iritis  im- 
properly treated  in  the  early  period  has  relapsed,  it  is  not  always  wise  or 


336  DISEASES    OF   THE    IRIS 

possible  to  induce  active  mercurialization.  For  them  bichlorid  com- 
bined with  the  tincture  of  iron  is  a  suitable  remedy.  Subconjunctival 
injections  of  bichlorid  of  mercury  (2  to  4  drops  of  a  1  :  2000  solution) 
are  efficient,  but  painful.  Acoin  added  to  the  injection  relieves  the 
pain.  In  place  of  the  bichlorid  solution  one  of  cyanid  of  mercury 
(1  :  5000)  is  advised  bj^  Darier.  Equally  good  results  are  obtained 
with  5-  to  15-minim  (0.3-0.02  c.c.)  injections  of  physiolop:ic  salt  solution 
if  there  is  not  too  much  circulatory  stasis.  The  injections  may  be 
given  every  second  or  third  da\',  and  should  be  followed  by  light  mas- 
sage of  the  eyeball.  Usually  they  are  not  necessary  if  active  constitu- 
tional treatment  (arsphenamin,  mercury)  has  been  carefullj'  carried 
out. 

2.  Rheumatism — Rheumatic  Iritis. — According  to  Kriickmann,  rheu- 
matic iritis  is  apt  to  begin  with  conjunctival  hyperemia  or  a  non-bac- 
terial conjunctivitis;  at  first,  in  some  cases,  there  may  be  mydriasis 
with  preservation  of  the  pupil  reflexes  and  congestion  of  some  of  the 
radially  placed  larger  iris  vessels,  followed  by  a  sudden  increase  of  the 
iris  injection  and  the  appearance  of  pericorneal  injection,  pupil  immo- 
bility, fibrous  exudation  into  the  superficial  stroma  layer,  and  fine  de- 
posits on  the  posterior  surface  of  the  cornea.  The  vitreous  remains 
clear. 

The  association  of  iritis  with  acute  rheumatism  (acute  rheumatic 
fever),  however,  must  be  exceedingly  uncommon,  if  it  ever  occurs. 
Indeed,  as  Kriickmann  maintains,  the  so-called  rheumatic  iritis  must 
be  sharply  separated  from  those  iritic  involvements  which  follow  or 
accompanj'  acute  joint  rheumatism,  and  which  tlepond  upon  metas- 
tasis of  staphylococci  or  streptococci  proceeding  from  purulent  jiroc- 
esses  in  the  joints.  Paine  and  Poynton  have  isolated  a  diplococcus 
which  they  regard  as  the  specific  cause  of  rheumatic  fever,  and  with 
which  experimentally  they  were  able  to  produce  an  iridocyclitis  which 
was  regarded  as  a  true  rheumatic  iridocyclitis.  In  so  far  as  acute 
rheumatism  is  concerned  these  observations  have  been  confirmeil  by 
Rosenow,  whose  investigations  also  indicate  that  muscular  rheumatism 
(see  below)  may  be  due  to  a  closely  related  streptococcus. 

Because  the  relation  of  rheumatism  to  the  development  of  iritis  is 
a  vague  one,  and  because  the  general  "rheumatic"'  c()nditions — myal- 
gia, joint  lesions,  etc. — may  be  toxic  in  origin.  T.  Harrison  Butler 
suggests  that  the  ocular  manifestation  shouUl  be  denominated  uuto- 
toxemic  or  toxemic  iritis,  and  that  the  term  "rheumatic"  should  be 
abandoned. 

3.  Aututoxemic  Iritis  (Iritis  with  Disorders  of  Nutrition  or  Constitu- 
tional Disorders). — Notably  l)etween  the  ages  of  twenty  and  fifty, 
but  also  at  later  periods  of  life,  either  coincident  or  not  with  affections 
which  are  usually  classified  as  ciuoiiic  rheumatism,  chronic  joint  rheu- 
matism, or  imisculai-  rheumatism  /.  <■.,  myalgia  manifesting  itself  as 
lumbago,  pleurodynia,  or  |)ain  in  various  groups  oi  muscles  (^usually 
classified  by  systematic  writers  as  "constitutional  diseases"  or  "dis- 
eases of  nutrition")    -iritis  is  ?iot   uncommon.      In  Butlc^r's  statistics 


IRITIS    AND    ITS    TYPES  337 

this  type  of  iritis  or  iridocyclitis  constitutes  6  per  cent.  It  varies  con- 
siderably in  the  aggressiveness  of  its  symptoms.  Not  uncommonly 
these  are  severe,  with  much  pericorneal  injection,  acute  pain,  greater 
usually  than  in  syphilitic  cases,  and  tenderness  of  the  globe.  Fre- 
quently only  one  eye  is  affected ;  the  inflammation  rarely  is  simultane- 
ously symmetric.  The  second  iris  may  be  affected  in  like  manner  after 
a  longer  or  shorter  interval.  From  the  subjects  of  this  form  of  iritis, 
if  none  of  the  various  types  of  polyarthritis  or  myalgia  is  present,  a 
history  of  such  an  affection  can  usually  be  obtained;  sometimes  the 
history  develops  the  fact  that  the  patient  has  suffered  from  sciatica,  or 
crural,  musculospinal,  and  other  forms  of  neuritis.  In  many  cases 
areas  of  focal  infection  (teeth,  tonsils,  sinuses,  intestinal  tract  etc.)  are 
in  evidence  and  are  related  etiologically  to  the  iritis  and  the  chronic 
rheumatism  and  myalgia,  each  being  manifestations  of  the  toxemia 
thus  produced. 

Relapses  are  frequent,  in  this  particular  differing  from  syphilitic 
plastic  iritis,  and  a  patient  once  having  had  an  attack  of  this  type  of 
iritis  (often  in  its  manifestations  an  iridocyclitis)  is  liable  at  intervals 
of  months  or  even  years  again  to  be  attacked.  If  treatment  is  begun 
early,  even  in  recurring  attacks,  perfect  cure  may  be  expected. 

The  frequent  relapses  of  some  varieties  of  the  affection  have  given 
rise  to  the  term  recurrent  iritis.  This  form  of  iritis  has  been  noted  in 
association  with  ictero-hemorrhagic  spirochetosis;  recurrent  iritis  with 
dermatitis  exfoliativa  has  been  reported  (S.  Gifford). 

A  form  of  iritis  exists,  aptly  called  quiet  iritis  (Hutchinson),  in 
which  there  is  no  pain  or  ciliary  congestion;  it  is  practically  non-adhe- 
sive, the  only  subjective  symptom  being  the  progressive  dimness  of 
vision,  which  leads  to  its  discovery,  and  which  is  associated  with  so- 
called  chronic  rheumatism  or  inherited  arthritic  tendency  or  the 
uratic  diathesis  in  a  majority  of  cases,  but  which  may  also  depend  upon 
syphilis.  A  variety  of  quiet  iritis  in  which  the  lesions  are  said  to  be 
confined  to  the  posterior  layer  of  the  iris  has  been  described  by  Grand- 
clement  under  the  name  "Uveite  irienne."  It  occurs  usually  in 
women  during  the  period  of  uterine  activity;  frequently  its  subjects 
are  anemic.  Grandclement  failed  to  associate  it  with  any  local  or 
general  malady.  One  variety  of  iritis,  moderate  in  its  manifestations, 
although  it  may  be  associated  with  small  hemorrhage  in  the  iris  tissue, 
is  due  to  arteriosclerosis  and  occurs  in  middle  aged  or  elderly  persons 
(Michel).  Iritis  in  the  course  of  chronic  nephritis  is  also  occasionally 
encountered. 

A  severe  and  sometimes  destructive  form  of  iritis  may  accompany 
arthritis  deformans.  There  is  a  variety  of  iritis  characterized  by  warty- 
looking  translucent  excrescences  at  the  pupil  margin,  generally  occur- 
ring in  women,  to  which  Doyne  has  given  the  name  guttate  iritis. 
(Compare  this  section  with  pages  349-355). 

With  two  constitutional  diseases  or  disorders  of  nutrition  iritis  or 
iridocyclitis  is  not  infrequently  associated,  nameh',  gout  and  diabetes. 

Gouty  iritis,  as  it  is  usually  called,  occurs  in  the  subjects  of  gout, 


338  DISEASES   OF   THE    IRIS 

irregular  gout  (often  referred  to  with  questionable  aceuracy  as  gouty, 
lithemic,  or  uric  acid  diathesis),  and  in  the  members  of  gouty  families. 
It  probably  depends  upon  the  defective  nitrogen  metabolism  which 
underlies  gout,  although  this  origin  is  not  accepted  by  some  authors. 
It  tends  to  relapse,  to  attack  one  eye  at  a  time;  the  superficial  layers 
of  the  iris  are  especially  affected.  It  may  precede  a  gouty  attack  else- 
where in  the  body.  A  form  of  iritis,  insidious  in  character  and  de- 
structive in  tendency,  almost  invariably  associated  with  disease  of 
the  vitreous,  occasionally  occurs  in  children  of  gouty  parents.  These 
children,  according  to  the  late  ]Mr.  Hutchinson,  have  a  pecuhar  square- 
ness of  build,  heavy  features,  florid  complexions,  and  feebleness  of  cir- 
culation in  the  extremities. 

Less  frequent!}'  iritis  (sometimes  purulent),  sometimes  associated 
with  fibrous  deposits  in  th(!  pupil  space  and  with  hemorrhage  in  the 
anterior  chamber,  develops  in  the  subjects  of  diabetes;  it  is  ordinarily 
described  as  diabetic  iritis.  Its  frequencj'-  among  diabetics  has  varied 
from  1.5  to  5  per  cent.  For  the  inflammation  of  iris  associated  with 
gout,  diabetes  and  hj-pothyroidism,  Duanc  proposes  the  names  metabolic 
iritis. 

Treatment. — The  use  of  atropin  in  the  manner  alreatly  described 
is  of  paramount  importance.  For  it  scopolamin,  gr.  ij  to  f5j  (0.13 
gm.  to  30  c.c),  may  be  subtituted,  or  the  two  drugs  may  be  com- 
bined. Leeches  and  moist  and  dry  heat  will  help  to  relieve  the  pain, 
and/ at  the  proper  stage,  subconjunctival  injections  of  salt  solution. 
Much  comfort  often  results  from  the  administration  at  night  of  ^loo 
grain  (0.00065  gm.)  of  hyoscin,  but  morphin  or  codein,  if  given  at  all, 
must  be  administered  with  great  caution  lest  the  patient  form  a  drug 
habit.  Rubbing  the  brow  with  an  ointment  of  mercury  and  bella- 
donna is  of  some  service.  Dionin  (5  per  cent.)  and  holocain  (2  per 
cent.)  act  well  in  relieving  pain. 

Much  reliance  may  be  placed  upon  salicylic  acid,  salicylate  of 
sodium,  salicylate  of  strontium,  and  aspirin;  of  these  remedies,  salicy- 
late of  sodium  is  the  best;  indeed,  it  relieves  the  pain  of  any  form  of 
iritis.  It  should  be  exhibited  in  full  doses,  00  to  80  grains  (3.9-5.2  gm.) 
during  the  first  twenty-four  hours,  and  afterward  the  amount  gradu- 
ally lessened. 

The  tendency  to  recurrence  rtHjuires  jireventivi*  treatment  in  the 
form  of  regulated  diet,  the  use  of  mineral  waters,  and  proper  attiMition 
to  change  of  clothing,  according  to  the  vicissitudes  of  the  climate.  A 
course  of  treatment  at  some  establishment  conniu'ted  with  the  various 
medicinal  springs  is  of  great  benefit.  In  all  ft)rms  of  iritis,  especially 
in  i\w  autotoxciMic  types,  the  nasopharynx,  tlu>  tonsils,  tlu'  teeth,  the 
accessory  sinuses,  and  the  buccal  mucous  membrane  should  be  carefully 
examined  for  focal  infection,  which  may  be  the  cause  of  the  toxemia 
of  which  the  patient  is  the  sul)j('ct  as  well  as  of  the  iritis  (see  also 
page  35-1).     Intestinal  sepsis  may  be  jjresent  and  must  be  corrected. 

If  the  iritis  assumes  a  chronii-  t>'pe,  or  if  there  has  been  exiulation  of 
lyni])h  (»r  iiivohciiiciit  of  the  cili.-iry  boily,  mercury  and  iodiil  of  i)otas- 


IRITIS    AND    ITS    TYPES  339 

sium  may  be  exhibited.  After  the  inflammatory  signs  of  iritis  have 
thorough!}'  subsided  and  the  eye  is  quiet,  the  refractive  error  should  be 
thoroughly  corrected  and  the  glasses  worn  constanth',  because  there 
is  no  doubt  that  this  plan  of  treatment  distinctly  checks  the  tendency 
to  relapse. 

Should  gout  be  determined  to  be  the  underljdng  cause,  the  usual  treat- 
ment of  this  affection — dietetic  and  medicinal — is  indicated,  in  addition 
to  the  local  measures.  ISIedicinal  springs  treatment  is  especially  val- 
uable.    The  subjects  of  gout  must  be  treated  on  general  principles. 

4.  Gonorrhea — Gonorrheal  Iritis  (Gonorrheai-rheumatic-iritis) . — This 
is  a  form  of  iritis  (often  a  severe  iridocychtis),  chiefly  plastic  in  charac- 
ter, does  not  necessarily  coincide  with  nor  immediately  follow  the 
gonorrheal  attack;  an  arthritis  of  the  knee,  or  sometimes  of  the  ankle, 
intervenes;  sometimes  arthritis  and  iritis  occur  at  the  same  time,  and 
sometimes  the  iritis  precedes  the  arthritis.  Brailey  has  seen  it  assume 
a  gelatinous  type.  This  disease  is  much  more  common  than  has  usu- 
ally been  supposed,  and  there  may  be  a  long  interval  between  the  ac- 
quisition of  the  gonorrhea  and  of  the  iritis — frequently  several  years 
and  even  as  long  as  thirty  years.  The  blood  should  be  examined  for  a 
complement-fixation  reaction,  and  the  posterior  urethra  for  gonococci. 
It  should  be  remembered  that  a  ordinary  plastic  iritis  in  a  person  with 
sj'phihs  may  be  due  to  a  gonorrhea  from  which  he  has  also  suffered. 
Chronic  forms  of  gonorrheal  iritis  resemble  chronic  endogenous  uveitis 
(see  page  349)  and  may  be  complicated  with  tuberculosis  (v.  Herren- 
schwand) .  In  many  instances  so-called  rheumatic  iritis  is  really  gonor- 
rheal in  origin;  indeed,  William  Lang  beheves  that  the  gonococcus  is  the 
the  most  frequent  cause  of  plastic  iritis.  The  affection  is  due  to  the 
influence  of  the  gonococci  and  their  toxins  on  the  iris.  The  presence  of 
these  micro-organisms  in  the  anterior  chamber  has  been  demonstrated 
(Sidler-Huguenin).  The  disease  is  attended  with  severe  pain,  in  add- 
ition to  the  usual  sj^mptoms  of  iritis,  and  its  chief  manifestations  are 
in  the  superficial  layers  of  the  iris.  It  may  relapse  with  each  new 
attack  of  gonorrhea. 

Treatment. — The  local  use  of  atropin,  etc.,  is  indicated.  If  the 
urethra  is  inflamed,  this  must  receive  attention.  lodid  of  potassium 
may  be  tried,  and  mercury,  if  there  is  much  exudation.  Relief  wiU 
follow  profuse  sweats  by  means  of  pilocarpin  given  hypodermicaUy 
or  with  the  aid  of  an  ordinary  hot  chamber  or  cabinet;  indeed,  these 
remedies  are  of  great  value  in  other  varieties  of  stubborn  iritis.  Sub- 
conjunctival injections  of  salt  and  of  cj'anid  of  mercury  have  been 
advocated,  and  dionin  in  the  usual  manner  may  be  emploj^ed.  Excel- 
lent results,  in  the  author's  experience,  follow  the  administration  of 
gonococcic  vaccine  (Neisser  bacterin).  Large  doses  are  tolerated: 
50,000,000  to  100,000,000  organisms  may  be  injected  at  intervals  of 
three  to  seven  days.  Even  larger  doses  are  advocated  bv  WiUiam 
Lang  (200,000,000"  to  500,000,000  at  intervals  of  a  week).  John 
Weeks,  however,  thinks  smaller  doses  (2,500,000  to  50,000,000)  pro- 
duce equally  good  results. 


340  DISEASES    OF   THE    IRIS 

Iritis  Secondary  to  Mucous  Membrane  and  Focal  Infection. 

— Iritis  (more  often  iridocyclitis  or  uveitisj  caused  by  infection  of  mu- 
cous membranes  is  of  freciuent  occurrence  and  has  been  referred  to 
in  the  discussion  of  autotoxemic  iritis.  The  primary  source  of  such  infec- 
tion most  frequently  is  a  chronic  septic  process  in  the  mouth  (pyorrhoea 
alveolaris),  in  the  teeth  (tooth-root  abscesses),  in  the  tonsil,  in  the 
nasopharynx,  in  the  accessory  nasal  sinuses,  in  the  middle  ear.  in  the 
stomach  and  intestines,  in  the  gall-bladder  and  appendix,  in  the  urethra 
(see  page  339),  in  the  uterine  cavity,  the  prostate,  the  seminal  vesicles, 
the  bladder  and  in  the  skin  (boils,  furuncles,  etc.). 

Treatment. — ^In  all  cases  of  iritis  and  iridocyclitis  the  regions  named 
must  be  carefully  searched  for  disease  and  persistently  treated  if  it  is 
present.  The  usual  local  ocular  treatment  is  indicated.  Vaccine 
therapy  (usually  the  staphylococcus  is  the  active  organism,  but  others 
may  be  potent)  may  be  efficient.  (For  additional  information,  see 
pages  354,  355.) 

In  malaria  a  periodic  iritis  with  hypopyon  has  been  described,  and 
somewhat  analogous  to  this  is  another  periodic  iritis,  or  iridocyclitis, 
which  has  been  seen  before  each  menstrual  period  {iritis  catamenalis), 
perhaps  due  to  abnormalities  in  the  uterine  discharge.  Fuchs  reports 
severe  iridocyclitis  in  association  with  general  alopecia.  A  relation 
between  nephritis  and  iritis  has  been  described.  Sometimes  plastic 
iritis  of  moderate  grade  is  found  in  elderly  persons  for  which  no  cause 
can  be  found;  to  these  t3'^pes  of  iritis  formerly  the  name  "idiopathic" 
was  ai)i)li('d. 

Tubercle  of  the  Iris  (Tuberculous  Iritis). — In  a  certain  nund)er  of 
persons,  usually  between  the  ages  of  five  and  twenty-five  small,  gray- 
ish-red or  yellowish  nodules  develop  at  the  margin  of  the  pupil  or  at  its 
ciliary  border,  bearing  great  similarity  in  their  external  appearance 
to  miliary  growths  {(lisscniinotcd  niilidri/  tubercle  of  the  iris).  The  nod- 
ules are  usually  2  to  3  mm.  in  diameter,  and  may  be  situated  close  to 
the  anterior  surface  of  the  iris  or  deep  in  its  stroma.  Two  terminations 
have  been  obseived:  the  growths  may  develop  slowl>'  and  finally  be 
absorbed  and  disai)])ear,  posterior  synechia^  renuiining  at  their  ))oints 
of  origin  (altenudtcd  tubercle  of  iris,  Leber);  or  successive  d(>velopments 
of  new  nodules  may  lead  to  a  plastic  infianunation  of  the  iris  and  cili- 
ary body,  and  involvement  of  the  cornea  (keratitis  punctata),  and  cause 
perforation  at  the  corneoscleral  junction,  and  shrinking  of  the  eyeball. 
In  llicse  circumstances  tubercle  of  the  iris  apjx'ais  in  the  form  of  an 
iridocyclitis  (uveitis).  In  some  cases  t)f  tuberculous  iritis  th(>  nodules 
are  ill-delined,  being  situated  within  the  inllamed  and  thickeneil  iris. 

Tubercle  of  the  iris  also  occurs  in  a  confluent  or  corKjlonierate  form,  a 
yellowish  nodule  growing  from  the  ])eri])hery  of  the  iris,  cov(>red.  it  may 
be,  with  smaller  bodies.  The. tendency  of  this  growth  is  to  incre.'ise,  to 
perforate  the  eye,  and  (o  cause  a  general  dissemination  of  tubercle. 

The  a\ei'age  age  of  persons  .MlVectcd  with  i)rimary  tul)erculosis  of 
llic  iris  is  tw(!lve  years;  one  or  Imili  eyes  ni;iy  be  alicctcd.  inoi'c  coin- 
riKdily  the  forMici'.      All  li«»ii!j;li  the  |)al  icits  iii;iy  |)r('S(Mil  no  (tl  her  signs 


TRAUMATIC   IRITIS  341 

of  tuberculosis,  this,  and  in  a  fatal  form,  may  become  a  sequence. 
Sometimes  the  affection  of  the  iris  is  secondary  to  the  general  disease. 
Bacilli  and  giant-cells  may  be  found  in  these  growths,  proving  their 
true  nature,  or  the  diagnosis  must  rest  upon  the  results  of  inoculation 
of  a  rabbit's  or  guinea-pig's  anterior  chamber  with  a  fragment  of  the 
suspected  tissue,  or  upon  tests  with  tuberculin,  either  by  means  of 
subcutaneous  injection  or  cutaneous  vaccination.  For  diagnostic  pur- 
poses Koch's  old  tuberculin  may  be  used  in  gradually  increasing  doses, 
beginning  with  1  mg.  and  with  two-day  inter\^als  increasing  to  5  mg. 

Treatment. — Removal  of  a  tubercle  of  the  iris  is  almost  always 
unsuccessful,  except  in  some  varieties  of  attenuated  tuberculosis. 
Hence,  if  the  disease  is  attacked  from  the  operative  standpoint,  enu- 
cleation has  been  recommended.  Before  radical  surgical  procedures 
are  adopted  there  should  be  a  thorough  trial  of  the  therapeutic  value  of 
tuberculin.  E.  von  Hippel,  using  tuberculin  T.  R.,  begins  with  the  dose 
of  }yioo  iiigv  and  gradually  increases  to  }io  mg.,  and  even  to  ^%o  mg. 
In  some  cases  the  dose  is  further  increased  from  3^^  mg.  to  % ;  i.e.,  1  mg. 
by  j-i  mg.  at  each  injection.  A  bouillon  filtrate  of  tuberculin  obtained 
from  the  Saranac  Laboratory,  with  the  initial  dose  of  0.0001,  mg,  is 
recommended  by  G.  S.  Derbj'.  The  author's  results  with  tuberculin 
as  a  therapeutic  agent  have  been  most  satisfactory.  He  has  also  used 
with  satisfaction  tuberculin  "  Old. "  The  five  dilutions  contain  respec- 
tively 1:1000  mg.,  1:100  mg.,  1:10  mg.,  1  mg.,  and  10  mg.  The 
dose  of  each  dilution  is  2  mg.,  and  is  progressivel}'  increased  until  20 
minims  are  injected.  Following  this,  the  next  series  is  begun.  The 
introduction  of  iodoform  into  the  anterior  chamber  has  been  tried. 
Phototherap3'  has  been  recommended  (Seidel).  With  these  methods 
of  treatment  the  author  has  had  no  experience. 

Scrofulous  iritis  occurs  usually  in  children  and  young  persons 
of  scrofulous  habit.  In  some  respects  it  resembles  inherited  syphilitic 
iritis.  Nodules  of  lardaceous  appearance  may  also  form.  Tuberculous 
iritis  is  described  on  page  340. 

Infectious  disease  iritis  is  seen  in  association  with  recurrent 
fever,  variola,  pneumonia,  pertus.sis,  parotitis,  tonsillitis,  herpes  zoster, 
cerebrospinal  meningitis,  influenza,  dysentery,  typhus  and  typhoid 
fever,  and  a  purulent  iritis,  as  the  result  of  embolism,  occurs  in  the 
course  of  septicemia  after  puerperal  fever,  and  in  p3'emia.  The  irido- 
cyclitis observed  in  association  with  dysentery  may  or  may  not  be 
accompanied  by  articular  disease  (Morax). 

The  management  of  such  cases  depends  upon  general  principles, 
the  free  use  of  quinin  and  stimulants  being  appropriate  in  purulent 
iritis. 

Traumatic  iritis  occurs  as  the  result  of  an  injury,  either  acci- 
dentally inflicted  or  due  to  an  operation — e.  g.,  cataract  extraction.^ 
In  this  category  are  placed,  also,  those  cases  of  iritis  which  follow  discis- 

^  Spongy  iritis  (see  page  332)  is  occasionally  seen  after  cataract  extraction. 
Plastic  iritis  has  been  ascribed  to  the  action  of  strong  solutions  of  eserin  (eserin 
iritis) ;  but  it  is  doubtful  if  the  drug  could  produce  such  an  effect  in  a  healthy  eye. 


342  DISEASES   OF   THE    IRIS 

sion  of  the  lens  and  which  depend  upon  swelling  of  the  cortical  material  or 
toxins  from  the  lens-material  and  infection  conveyed  through  the  wound. 
The  iritis  excited  by  foreign  bodies — for  instance,  metallic  particles — 
embedded  in  the  iris  has  been  ascribed  to  a  chemic  as  well  as  to  in- 
fective action. 

Treatment. — The  usual  local  measures  arc  advisable.  Iced  com- 
presses are  advantageous,  and  the  internal  administration  of  mercury 
and  the  salicylates  is  indicated. 

Sympathetic  iritis  (see  page  360). 

Secondary  iritis,  independently  of  the  fact  that  in  a  certain  sense 
all  types  of  iritis  arc  secondary,  may  depend  upon  exogenous  sepsis, 
for  example,  that  which  results  from  an  infected  corneal  wound  (see 
Traumatic  Iritis)  or  upon  exogenous  toxemia,  for  instance,  that  which 
proceeds  from  an  infected  corneal  ulcer  (see  page  265). 

Scleritis  of  the  deep  variety  is  often  associated  with  iritis.  More 
rarely  the  primary  disease  begins  deep  in  the  eye — e.  g.,  in  detachment 
of  the  retina.  The  presence  of  intra-ocular  tumors,  vitreous  exuda- 
tions, or  retinal  hemorrhages  may  occasion  a  secondary  iritis. 

Serous  Iritis. — At  one  time  it  was  the  custom  to  describe  a  form 
of  iritis  characterized  by  a  serous  or,  more  commonly,  a  seroplastic 
exudation,  deepening  of  the  anterior  chamber,  slight  dilatation  of  the 
pupil,  haziness  of  the  cornea  and  aqueous  humor,  and  a  precipitate  of 
opaque  dots  upon  the  posterior  surface  of  the  cornea,  generally  arranged 
in  a  triangular  manner,  with  the  apex  pointing  upward,  with  the 
term  serous  iritis,  or  serous  iritis  and  keratitis  pu7ictata  (see  page  351). 
Both  of  these  terms  are  inappropriate,  the  one  indicating  purely  a  symp- 
tom of  a  disease,  and  the  other  an  unproved  pathologic  condition. 
For  a  full  consideration  of  this  matter,  see  page  349. 

Chronic  Iritis. — Any  type  of  iritis  may  assume  an  acute,  subacute, 
or  chronic  course;  if  the  last,  no  additional  symptoms  occur,  but  those 
ordinarily  present  are  modified  by  the  chronicity  of  the  stages. 

In  addition  to  the  chronic  typo  of  an  ordinary  iritis  there  remains 
to  be  described  one  which  has  received  the  name  plastic  iridoclwroiditis, 
because  of  co-existing  disease  of  the  choroid  and  vitreous,  leailing  to  the 
formation  of  a  secondary  cataract.  This  disease  occurs  in  adults,  often 
without  assignable  cause,  is  symmetric,  and  proceeds  steadily  in  a  tend- 
ency destructive  to  the  nutrition  of  the  eye  (see  also  page  352). 

The  treatment  of  the  latter  condition  is  unsatisfactory,  alteratives, 
tonics,  and  operative  measures  often  meeting  with  indifferent  success. 

Operative  Treatment  in  Iritis, — Paracentesis  of  the  cornea  may  be 
needed  to  re(kice  c-ontinued  elevation  of  tension  in  some  forms  t>f  iritis, 
and  has  l)een  advised  as  a  tiierapeutic  measure  in  sonu^  varieties  of 
iridocyclitis.  Should  inflanjmation  of  the  iris  and  hypopyon  exist,  tlie 
treatment  already  descril)ed  (.see  page  273)  is  nMiuired. 

Iridectomy  is  often  recommended  for  the  relief  of  recurrent  iritis, 
or  in  an  iritis  which  refuses  to  heal  eoiiiplelely,  some  ciliary  injection 
and  irritability  icniaining.  Those  eyes  which  jiresent  the  least  change 
in  the  iris,  in  uliicli  I  he  aciueoiis  luuiior  is  cleai"  ;ind  the  tension  is  not 


CHRONIC    IRITIS 


343 


subnormal,  are  most  likely  to  yield  a  good  result.  Iridectomy  in  recur- 
rent iritis  does  not  insure  the  patient  against  future  attacks,  and  repre- 
sents a  method  of  treatment  which,  in  the  author's  experience,  is  oiten 
unsatisfactory  except  as  it  may  be  required  to  relieve  increased  intra- 
ocular tension. 

In  chronic  iritis,  circular  posterior  synechise  and  bulging  of  the 
iris  are  important  indications  for  the  operation.  Determined  rise  of 
tension  and  threatening  glaucoma,  in  any  circumstances,  furnish  im- 
perative reasons  for  its  performance.  According  to  the  late  Mr. 
Nettleship,  keratitis  punctata,  chronic  thickening  of  the  iris  with  very 
extensive  attachments,  the  existence  of  myopia,  a  tendency  to  spon- 
taneous bleeding,  and  hypopyon  render  the  operation  less  desirable; 
if  the  tension  is  below  the  normal,  the  operation  may  be  followed  by 
bleeding  and  shrinking  of  the  eyeball;  occasionally,  even  in  these  cir- 
cumstances, excellent  results  are  achieved.     If,  however,  a  chart  of  the 


'^^''^K<(«Y!J?)>>^^^"''^'/ 


Fig.   148. — Cyst  growing  from  posterior  Fig.   149. — Cyst  of  the  iris  following 

surface  of  the  iris  advancing  into  the  anterior  traumatism  (froin  a  patient  in  the  Uni- 

chamber   (from   a  patient  in  the  University  versity  Hospital). 
Hospital). 


visual  field,  sometimes  obtainable  only  with  a  small  point  of  light, 
indicates  extensive  deep  disease,  the  chances  of  operative  success  are 
notably  lessened  and  the  operation  may  be  contraindicated. 

An  iridectomy  is  performed  to  secure  one  or  all  of  three  ends:  (1) 
Prevention  of  recurring  attacks;  (2)  re-establishment  of  the  communi- 
cation between  the  anterior  and  posterior  chambers  of  the  eye,  and 
thereby  improvement  in  nutrition  and  prevention  of  threatened  glau- 
coma; (3)  improvement  in  vision  by  the  substitution  of  an  artificial 
pupil  for  one  that  has  been  occluded  or  excluded. 

That  portion  of  the  iris  should  be  selected  for  excision  which  is  least 
changed  and  least  bound  down  by  adhesions. 

Posterior  synechise  remaining  after  the  acute  symptoms  of  iritis 
have  subsided  have  been  regarded  as  a  cause  of  relapse  or  recurrence, 
and,  although  this  has  not  been  proved  (compare  with  page  331), 


344  DISEASES    OF   THE    IRIS 

several  operations  have  been  devised  for  severinfj;  such  attachments,  to 
which  the  general  term  corelysis  has  been  apphed. 

Tumors  of  the  Iris. — Cysts. — Cj'sts  having  transparent,  deUcate 
walls  lined  witii  jKivenient  ejiithelium  (serous  qj.sts;  retention  cysts) 
may  be  congenital  or  may  develop  in  the  iris  as  the  result  of  an  injury. 
They  are  due  to  closure  of  the  mouth  of  an  iris  crypt  and  its  distention 
with  the  retained  fluid.  Cj'sts  formed  by  a  separation  of  the  two  layers 
of  the  pigmented  retinal  epithelium  at  the  back  of  the  iris  (cysts  of  the 
retinal  epithelium)  are  due,  according  to  Treacher  Collins,  to  interfer- 
ence with  the  h'mph-cuprent  of  the  iris.  Multiple  cysts  may  develop 
on  the  posterior  surface  of  the  iris  (Pagenstecher,  Fuchs,  Wintersteiner). 
Such  a  cyst  may  have  a  brownish  color  and  be  mistaken  for  a  malignant 
tumor.  A  parasitic  cyst — that  is,  one  due  to  cysticercus  in  the  iris — has 
been  reported.  Implantation  of  a  cilium,  or  of  superficial  epithelium, 
in  the  anterior  chamber  may  be  the  starting-point  of  an  ep/7/?f //a/,  pear/- 
like  tumor  (pearl-cysts  or  cholesteatoma) ,  essentially  cystic,  with  a  lining 
of  laminated  epithehum  and  semisolid  contentsof  degenerated  epithelial 
cells  and  fat-globules  (F.  R.  Cross  and  E.  T.  Collins).  Traumatic  cysts, 
which  owe  their  origin  to  the  intrusion  through  a  wound  of  corneo- 
conjunctival  epithehum,  which  proliferates,  are  divided  by  J.  Meller  into 
iris-cysts  proper,  which  are  situated  entirely  within  the  iris  tissue,  iris- 
chamher  cysts,  which  are  situated  partly  in  the  iris  and  jiartly  in  the  an- 
terior chamber,  and  wall-chamber  cysts,  which  are  so  situated  that  the 
iris  forms  only  part  of  their  boundary  wall. 

A  cyst  may  be  minute,  or  grow  and  fill  the  anterior  chamber;  both 
eyes  may  be  affected,  and  some  instances  of  multiple  iris-cysts  are  on 
record  (see  page  343).  A  cyst  may  cause  iridochoroiditis  by  jiressure. 
An  attempt  should  be  made  to  remove  it  through  an  incision,  the 
growth  and  surrounding  iris  being  seized,  drawn  out,  and  excised. 

Sarcoma  of  the  iris  is  rare  as  a  primary  growth.  It  has  been  well 
studied  in  this  country  by  Veasey,  and  more  recently  by  C.  A.  Wood 
and  Brown  Pusej'.  Iris  sarcoma  is  more  common  in  the  latter  half  of 
life — thatis,  after  thirty  years — than  at  an  earlier  period,  although  a  few 
cases  have  been  reported  in  the  first  decade  of  life.  Females  are  more 
often  affected  than  males;  the  lower  half  of  the  iris  is  the  primary  seat 
of  the  growth  in  a  large  percentage  of  the  ca.ses.  -\  few  instances  of 
bilateral  iris  sarcomas  are  on  record.  The  first  stage  of  the  tunior's 
growth  is  slow,  and  may  last  for  months  and  even  years;  in  the  second 
and  later  stages  there  is  rapid  increase  in  size,  with  jviin,  hemorrhage, 
etc.,and,finall3',rui)ture  of  the  globe.  Usually  the  tumor  is  pigmtMited; 
rarely  a  leukosaicoina  of  the  iris  develojjs.  Histologically  small 
round  and  small  spindle  cells  are  the  i)re(l(HMinating  forms.  The  growth 
must  be  differentiated  from  melanoma,  tubercle,  and  gumma.  \ 
few  iris  .sarcomas  have  been  successfully  removed  by  iridectomy 
(Thorington) ;  but  Wood  and  Puscv  are  eniph;itic  in  their  advice 
that  the  globe  sli.ill  be  ctniclc.-ihMl  ;is  soon  as  (he  diagnosis  is  certainly 
established. 

MelanoiiKi  of  the  iris  is  ;i  d.-irk  tiiuioi-,  dcxt'lopcd  fioiii  (lit-  pigment 


INJURIES    OF    THE    IRIS  345 

stroma  of  the  iris,  and  although  commonly  passive  and  innocuous,  is 
occasionally  the  precursor  of  sarcoma.  Melanomas  also  occur  at  the 
pupillary  margin  of  the  iris,  where  they  develop  from  the  retinal  pig- 
mented cells. 

Rare  forms  of  iris  tumor  are  vascular  growths  (nevi),  leprosy  no- 
dules, and  myomas.  It  is  more  than  doubtful  if  primary  carcinoma  of 
the  iris  occurs;  it  may  develop  as  a  secondary  growth,  as  also  may 
glioma.  Metastatic  carcinoma  of  the  iris,  secondarj^  to  breast  carcinoma 
has   been  reported  (Toulant,  Proctor). 

Injuries  of  the  Iris. — Wounds. — An  incised  wound  limited  to  the 
iris  does  not  necessarily  produce  serious  results.  It  will  be  followed  by 
blood  in  the  anterior  chamber,  which  in  course  of  time  is  absorbed. 
Wounds,  however,  are  rarely  hmited  to  the  iris,  but  having  penetrated 
the  eyeball  through  the  cornea  or  cihary  region,  may  cause  sympathetic 
irritation,  or  injure  the  lens  and  produce  traumatic  cataract. 

In  the  first  instance  atropin,  to  secure  physiologic  rest  of  the  iris, 
and  a  compressing  bandage  will  lead  to  a  speedy  cure;  in  the  other  in- 
stances the  extent  and  position  of  the  wound  will  determine  the  neces- 
sity for  enucleation  or  for  the  treatment  applicable  to  traumatic  iritis. 

Foreign  Bodies. — A  foreign  body  may  penetrate  the  cornea  and 
lodge  in  the  iris,  or,  having  partially  penetrated  the  cornea,  may  be 
pushed  through  it  in  the  efforts  at  dislodgment  and  become  entangled 
in  the  iris.  These  foreign  bodies  include  fragments  of  iron,  steel, 
shrapnel,  stone  and  wood,  and  detached  cilia,  which  passing  in  through  a 
corneal  wound,  have  become  attached  to  the  iris.  During  the  past  war 
particles  of  un burnt  cordite  penetrating  the  cornea  and  lodging  in  the 
iris  proved  to  be  a  serious  ocular  accident  in  many  soldiers. 

An  opening  is  made  with  a  broad  needle  or  narrow  keratome  at  the 
corneoscleral  junction,  eserin  having  been  previously  instilled,  and  a 
pair  of  forceps  passed  into  the  wound,  with  which  the  body  is  seized,  or 
a  small  loop  of  platinum  wire  may  be  slipped  beneath  the  fragment,  by 
means  of  which  it  is  withdrawn.  If  this  is  not  possible,  the  piece  of  iris 
in  which  the  substance  is  entangled  may  be  drawn  through  the  wound 
and  excised.  If  the  body  is  composed  of  steel  or  iron,  it  can  be  dis- 
lodged with  a  magnet. 

Blows  upon  the  eye  may  cause  the  following  lesions: 

Iridodialysis  is  a  rupture  of  the  ciliary  attachment  of  the  iris  (liga- 
mentum  pectinatum).  By  this  means  an  opening  is  produced  compar- 
able to  a  false  pupil;  it  may  be  detected  by  the  red  reflex  which  shines 
through  the-  artificial  aperture,  usually  somewhat  semilunar  shaped, 
situated  in  the  periphery  of  the  iris  at  the  corneoscleral  margin  (Fig. 
150).  This  maj'  be  quite  small  or  involve  more  than  half  the  circum- 
ference.    The  injury  may  produce  other  lesions — for  example,  cataract. 

In  a  few  instances  reattachment  of  the  ruptured  fibers  has  taken 
place  under  the  favoring  influence  of  atropin,  which  should  be  vigor- 
ously instilled.  An  operation  whereby  the  detached  border  is  replaced 
and  held  in  place  with  a  stitch  has  practised  with  success  (Bulson) .  Or- 
dinarily the  lesion  is  permanent  and,  if  small,  occasions  little  trouble, 


346  DISEASES    OF   THE    IRIS 

although  there  may  bo  (liplo])ia.  Pain,  some  dread  of  Hght,  and  hem- 
orrhage into  the  anterior  chamber  are  the  immediate  sequences  of  such 
an  accident. 

Rupture  of  the  sphincter  ])ro(hicos  mydriasis  and  minute  notchings 
of  the  pupil  l)ordor.  The  n(jt  uncommon  dilatation  of  the  i)upil  (trau- 
matic mydriasis)  wliich  follows  a  blow  is  always  accompanied  b}'  such 
a  lesion.  The  condition  is  not  altered  by  treatment.  Rupture  of  the 
continuity  of  the  iris  membrane  by  concussion  is  very  rare. 

Displacement  of  the  iris  occurs  imdor  throe  forms:  (1)  Retroflexion, 
or  a  folding  back  of  a  portion  of  the  iris  upon  the  cihary  processes, 
usually  accompanied  by  a  partial  dislocation  of  the  lens;  (2)  anierersion, 
or  turning  upon  itself  of  the  detached  portion  of  the  iris,  so  that  the 
under  or  uveal  surface  is  exposed;  and  (3)  aniridia,  or  complete  detach- 
ment of  the  iris  from  its  insertion,  so  that  it  lies  in  the  anterior  chamber, 
or  even  under  the  conjunctiva.  An  injury  severe  enough  to  produce 
this  condition  usually  is  attended  with  other  serious  lesions  of  the 


Fig.    150. — -Iridodialysis  and  partial  cataract;  pupil  dilated. 

remaining  structures  of  the  eye.  In  some  cases,  however,  the  aniridia 
is  the  sole  injury  and  vision  is  not  materially  disturbed.  In  one 
patient  under  tiie  author's  care,  the  iris  having  boon  com])lotoly 
detached  as  the  result  of  the  coming  violently  in  contact  with 
a  sharp  iron  rod,  vision  is  entirely  normal  with  a  correcting  glass, 
blackened  except  at  a  central  area  corresponding  in  size  to  the  pupil. 

ANOMALIES  OF  THE  ANTERIOR  CHAMBER 

J.  Alterations  in  its  Depth.  Physiologically,  the  anterior  {cham- 
ber is  shallower  in  infancx'  and  old  atic,  and  diniiiiishos  in  its  niid(llo 
depth  tlui'ing  the  act  of  accoiiiniodalion. 

Pathologic  deepening  of  the  antciior  chainbcr  occurs  in  luxation 
or  absence  of  the;  lens,  in  some  cases  of  cyclifis,  and  is  jmcsoiiI  in  conical 
cornea  and  cei'fain  forms  of  staphyloma  and  in  bui)litlialiuos. 

I*athologic  shallowing  of  the  anterior  chamber  occurs  in  chrcuiic 
iritis  witii  bulging  foiwaid  of  the  iris,  in  glaucoma,  and  in  the  later 
stages  of  growtlis  of  the  inleiioi-  of  the  eye.      Its  (lej)th  is  also  l(>ssened 


TUMORS  AND  CYSTS  OF  THE  ANGLE  OF  THE  ANTERIOR  CHAMBER  347 

where  there  is  diminution  of  the  secretion  of  aqueous  humor,  in  long- 
standing inflammation  of  the  uveal  tract  with  detachment  of  the  retina. 

2.  Alterations  in  its  Contents. — These  may  consist  in  mere 
turbidit}^  of  the  aqueous,  as  in  iritis,  keratitis  punctata,  and  glaucoma, 
or  there  may  be  a  positive  collection  of  pus,  several  times  referred  to 
under  the  name  of  hypopyon,  and  commonly  seen  in  sloughing  ulcers 
of  the  cornea  and  purulent  inflammations  of  the  iris  and  ciliary  body. 

Finally,  blood  collects  in  the  anterior  chamber,  a  condition  which 
receives  the  name  hyphemia.  This  follows  injur}^  to  the  iris,  and  occurs 
in  tumors  of  the  eye,  hemorrhagic  glaucoma,  and  in  severe  forms  of 
iritis  and  cyclitis.  It  is  also  seen  in  hemophilia  and  splenic  leukemia 
(Sorger).  Blood-staining  of  the  cornea  may  cause  a  peculiar  smoky 
hue,  resembling  a  lens  luxated  into  the  anterior  chamber  (see  also 
page  301). 

3.  Foreign  Bodies  and  Parasites. — A  foreign  body  penetrating 
the  cornea  may  lodge  upon  the  iris  or  fall  into  the  anterior  chamber. 
This  may  be  a  fragment  of  iron  or  steel  or  a  particle  of  glass  or  any 


Fig.    151. — Cilia  in  the  anterior  chamber  after  wound  of  corneoscleral  junction. 

of  the  substances  mentioned  on  page  318.  Sometimes  a  cilium  passing 
through  a  wound  obtains  entrance  into  the  anterior  chamber;  if  it 
remains  long  enough,  it  causes  a  cystic  tumor  (implantation  cyst). 

The  two  parasites  described  in  this  situation  are  Cysticercus  and 
Filaria  sanguinis  hominis.  In  all  these  instances  the  intruder  should 
be  removed  by  an  operation. 

4.  Tumors  and  Cysts  of  the  Angle  of  the  Anterior  Chamber. 
— According  to  Parsons,  endothelioma  is  the  only  primary  growth  of 
the  angle  of  the  anterior  chamber.  A  tumor  of  this  character,  its  cells 
being  derived  from  the  pectinate  ligament,  has  been  described  by 
Hanke.  Tubercle,  gumma,  sarcoma,  and  ghoma  occur  as  secondary 
deposits  in  this  region.  Cysts,  derived  from  a  congenital  cystic  growth 
of  the  cihary  epithehum,  may  develop  in  the  anterior  chamber  (Holmes 
Spicer,  R.  A.  Greeves). 


CHAPTER  X 

DISEASES   OF  THE  CILIARY  BODY  AND  SYMPATHETIC 
IRRITATION  AND  INFLAMMATION 

Cyclitis  and  Iridocyclitis. — Under  the  general  term  cyditis  arc 
included  various  types  of  inflammation  of  the  ciliary  body.  The  close 
anatomic  connection  of  the  iris,  choroid,  and  ciliary  body  makes  dis- 
eases limited  sti'ictly  to  the  last  structure  exceedinjily  uncommon,  just 
as  in  man}'  instances  inflammations  primary  in  the  iris  or  choroid  also 
involve  the  ciliary  bod\\ 

Hence  if  the  iris  and  ciliary  body  are  associated  in  pathologic 
changes,  the  term  iridocyclitis  is  applicable. 

The  symptoms  which  justify  the  diagnosis  of  cyclitis  or 
iridocyclitis  are  the  following:  Edema  of  the  lid,  injection  of  the  cir- 
cumcorneal  or  ciliary  zone,  neuralgic  pain,  and  tenderness  on  pressure. 
Change  in  the  aqueous  humor,  which  grows  turbid;  percipitates  of 
exudation  in  grajash-brown  points  upon  the  posterior  layer  of  the 
cornea,  and  at  times  hypopyon;  exudation  in  the  posterior  chamber, 
attaching  the  under  surface  of  the  iris  to  the  lens-capsule  in  a  complete 
posterior  synechia,  the  retraction  thus  produced  causing  a  deepening 
of  the  anterior  chamber;  exudation  into  the  vitreous  causing  opacities, 
especially  in  its  anterior  layers;  and  alterations  in  the  tension  of  the 
globe,  which  may  be  increased  or  decreased. 

The  general  symptoms  of  pain,  photophobia,  lacrimation,  etc.,  are 
present  in  the  acute  tj'pes  of  the  disease,  and  vision  is  seriously  im- 
paired according  to  the  amount  of  the  exudation  in  the  pujiillary  space 
and  vitreous. 

To  those  cases  characterized  by  especially  severe  ciliary  pain  and 
marked  pericorneal  injection,  dilatation  of  the  veins  of  the  iris  and 
decided  retraction  of  its  periphery  by  reason  of  the  i)lastic  nature  of  the 
exudate  in  the  ciliar}'  body,  the  descriptive  name  i)l(istic  cyclitis  is  often 
given.  The  intra-ocular  tension  may  be  high  or  low,  according  to  the 
grade  of  the  inflamnuition  and  the  character  of  the  process.  The 
disease  may  involve  the  choroid,  and  the  vitreous  may  be  filled  with 
opacities.  If  the  pain  is  comparatively  slight  and  tiie  pericorneal 
injection  less  markccl,  while  decpciiiiiir  of  the  anterior  chamber,  jiri- 
mary  slight  dilatation  of  the  pupil,  turl)idity  of  the  aiiuei>us,  and 
decided  precipitation  of  dots  on  the  posterior  surface  of  the  cornea 
("keratitis  punctata")  are  consjjicuous  fe.'itures,  th(^  d(\scriptiv(^  name 
serotis  cyclitis  is  sometimes  ajjpiicMJ.  \\'itli  these  phenomena  fine 
vitreous  oi)aci(ies,  inManunation  of  the  iris  and  clioioid,  narrowing  of 
the  anterior  cli;imbei-,  increased  le?ision,  and  secondary  glMuc»>ma  may 
be  associated. 
IMS 


UVEITIS,    OR   SEROUS    CYCLITIS  349 

Purulent  cyditis  is  characterized  by  intense  ciliary  pain,  great  peri- 
corneal injection,  and  edema  of  the  conjunctiva  and  the  upper  lid. 
The  vitreous  contains  large  opacities,  and  a  noteworthy  feature  is  the 
formation  of  hypopyon,  which  may  disappear  and  reappear  in  a  few 
days,  its  reappearance  sometimes  being  signaled  by  a  fresh  exacerba- 
tion of  intense  pain.  The  iris  and  choroid  commonly  are  included  in 
the  inflammation. 

Pathology. — As  alread}^  noted,  systematic  writers  at  one  time  were 
accustomed  to  divide  c.ychtis  into  plastic,  serous,  and  purulent  cyclitis. 
The  objections  to  a  classification  of  this  character  have  been  recorded 
in  connection  with  iritis  (see  page  331).  In  general  terms,  inflamma- 
tion of  the  ciliary  body  may  be  acute,  suppurative  or  purulent,  and 
chronic.  In  addition  to  the  infiltration  of  the  iris  and  exudation  in  the 
anterior  chamber,  there  are  round-cell  infiltration  of  the  ciliary  body, 
much  more  intense  in  the  vascular  ciliary  processes  than  in  the  ciliary 
muscle,  and  lines  of  exudation  into  the  posterior  chamber  and  the 
vitreous.  The  retina,  choroid,  and  nerve  are  also  involved  in  a  varjing 
degree.  Later  the  exudations  organize  and  contract,  producing  atrophy 
of  the  ciliary  bod}',  prohferation  of  the  pigment  layers,  and  stretching 
of  the  processes  toward  the  posterior  pole  of  the  lens.  The  exudations 
contain  newly  formed  vessels,  the  lens  becomes  cataractous,  and  if  the 
inflammation  has  been  intense,  the  retina  is  detached  and  atrophy  of  the 
entire  eyeball  results.  If  the  ultimate  result  of  cychtis  is  phthisis  bulbi, 
the  pathologic  process  has  been  a  chronic  plastic  cyclitis,  with  an  exuda- 
tion rich  in  fibrin  which  has  gradually  changed  into  fibrous  tissue. 

Prognosis. — Cyclitis  under  vigorous  treatment,  begun  early,  may 
subside;  but  the  prognosis  is  always  grave,  because  the  disease  is 
liable  to  originate  glaucoma,  and  in  the  purulent  type,  or  in  the 
plastic  variety  which  has  become  purulent,  tends  to  produce  atrophy 
of  the  iris  and  choroid  and,  as  described  above,  phthisis  bulbi. 

Shrunken  balls  of  this  character  are  often  tender,  readily  become 
inflamed,  and  may  produce  sympathetic  ophthalmitis;  this  is  particu- 
larh'  true  if  the  original  inflammation  has  been  a  cychtis  of  the  plastic 
type,  which  probably  remains  in  a  chronic  state. 

Causes. — As  already  stated,  primary  and  uncompHcated  disease  of 
the  ciliary  body  is  rare.  The  affection  usually  is  part  of  a  process 
which  involves  the  choroid  or  iris,  and,  therefore,  the  same  conditions 
and  affections  which  cause  iritis  (see  page  326)  may  originate  cychtis. 
A  full  consideration  of  the  factors  concerned  with  disease  of  this  region 
will  be  found  on  pages  350  and  351,  and  also  in  the  section  devoted  to 
Diseases  of  the  Iris. 

Injuries  are  common  causes  of  cyclitis,  and  the  inflammation  may 
follow  operations  upon  the  globe — e.  g.,  cataract  extraction. 

The  treatment  of  cyclitis  is  practically  identical  with  that  of  iritis, 
and,  therefore,  the  directions  need  not  be  repeated. 

Uveitis,  or  Serous  Cyclitis  {Descemetitis;  Aquocapsulitis;  Kera- 
titis Punctata;  Serous  hitis). — In  this  disease  the  clinical  as  well  as  the 
pathologic  manifestations  are  chiefly  concerned  with  the  uveal  tract. 


350      DISEASES  OF  CILIARY  BODY  AND  SYMPATHETIC  INFLAMMATION 

The  inflammatory  process  either  affects  the  whole  tract  or,  first  con- 
fined to  one  part  of  it,  is  liable  to  extend  to  one  or  both  of  the  other  two 
parts;  sometimes  it  remains  confined  to  the  part  first  attacked. 

Causes. — In  general  terms,  the  causes  of  uveitis  may  be  septic  or 
toxic.  A  certain  number  of  cases  depend  upon  so-called  constitutional 
diseases  or  disorders  of  nutrition — for  example,  chronic  rheumatism, 
gout,  arthritis  deformans,  and  diabetes;  on  disturbances  of  the  internal 
secretion — hj'pothjToidism;  on  specific  infectious  diseases — influenza, 
syphilis,  gonorrhea,  tuberculosis,  and  specific  fevers;  on  diseases  of  the 
blood — for  instance,  anemia;  on  auto-intoxications,  particularly 
enterogenous  auto-intoxication;  on  areas  of  sepsis  (focal  infections)  in 
the  pelvic  region,  urethra,  bladder,  the  prostate  and  seminal  vesicles, 
the  intestines,  gall-bladder,  appendix,  the  middle  ear,  the  rhino- 
pharynx  and  accessory  sinuses,  gums  (pyorrhoea  alveolaris,  tooth-root 
abscess),  the  tonsils,  the  pharyngeal  ring,  and  the  skin  (furuncles). 
(See  also  page  340.)  Iritis  and  uveitis  have  developed  after  anti- 
t3'phoid  inoculations. 

Stock's  investigations,  both  from  the  chnical  and  the  experimental 
standpoint,  indicate  that  tuberculosis  is  a  frequent  cause  of  chronic 
uveitis.  Hence,  tests  to  determine  the  presence  of  tuberculosis  should 
not  be  neglected  in  the  study  of  this  alTection,  and  the  serum  reaction 
of  Wassermann  should  be  utihzed  to  estabUsh  the  presence  or  absence 
of  syphilis  as  an  etiologic  factor.  Undoubtedly  gonorrhea  is  a  cause  of 
importance.  Inasmuch  as  most  of  the  inflammatory  affections  of  the 
iris  and  ciHarj'  body  are  due  to  microbic  infection,  there  exist  good 
grounds  for  believing  that  the  proximate  cause  of  all  cases  of  endo- 
genous iridocyclitis  is  the  excretion  by  the  cihar}^  body  of  the  micro- 
organisms and  their  products  (Stephenson).  As  alread}'  pointed  out 
(see  page  340),  and  quoting  Stephen  Mayou,  it  may  be  said  that  non- 
suppurative inflammation  of  the  uveal  tract  is  often  due  to  pyogenic 
organisms  of  diminished  virulence,  for  example.  Staphylococci,  derived 
from  the  distant  foci  of  infection  which  have  been  named  and  it  has 
been  attributed  to  pneumococcus  and  streptococcus  recovered  from 
feces  especially  in  chronic  colitis  (Browning)  and  to  the  Bacterium  coli 
found  in  the  urine  (Lawson).  In  areas  of  dental  infection  the  usual 
micro-organisms  (staphylococci,  etc.)  are  found  as  well  as  the  Strepto- 
coccus viridans.  The  mechanism  of  focal  infections  in  relation  to  the 
uveal  tract  inflammation  from  this  source  or  indeed  any  source, 
accepting  the  theory  of  selective  tissue  affinity  of  certain  bacteria, 
that  is,  elective  localization  may  l)e  stated  thus:  bacteria  find  favor- 
able o])i)ortunities  for  growth,  nmltiplication,  and  entrance  into  the 
lymphatic  streams,  not  only  by  means  of  ulceration,  but  possibly 
by  being  carried  in  by  niigrMtory  leukocytes  acting  as  phagocytes. 
Having  gained  access  to  tiie  blood  streams,  they  may  be  able  to  resist 
the  bactericidal  action  of  the  blood  by  reason  of  reiluction  in  the  re- 
sistance of  the  blood  due  to  the  primary  infection.  Subsequently 
they  may  locate  in  certain  tissues,  for  instance,  the  uveal  tract,  either 
because  they  Imve  (leveloi)ed  ;i  special  .Mffinily  for  these  |);ir(s  ;ui<l  find 


UVEITIS,    OR    SEROUS    CYCLITIS 


351 


conditions  favorable  for  their  growth,  or  because  the  resistance  of  these 
parts  is  reduced  by  some  other  agency  and  therebj^  favors  the  locali- 
zation of  the  germ  (Kolmer). 

Symptoms. — In  large  measure   the  symptoms  of  this   condition 
have  been  described  on  pages  294  and  342,  and  in  the  paragraphs 


Fig.  152. — Uveitis,  early  stage;  large  dots 
irregularly  placed  (magnified). 


'Fig.  15.3. — Uveitis;  large  dots  on  posterior 
corneal  surface  (magnified). 


relating  to  the  various  types  of  cyclitis.  In  other  words,  the  mani- 
festations vary  considerably,  and  one  description  does  not  apply  to 
all  types. 

The  following  symptoms  are  often  present,  and  when  grouped  to- 
gether are  characteristic:  There  are  moderate  deepening  of  the  ante- 
rior chamber,  at  the  beginning 
slight  dilatation  of  the  pupil  (or,  at 
least,  an  uncontracted  pupil),  hazi- 
ness of  the  cornea  and  aqueous 
humor,  and  a  precipitate  of  opaque 
dots  upon  the  posterior  elastic 
lamina  of  the  cornea,  generally  ar- 
ranged in  a  triangular  manner  with 
the  apex  pointing  upward.  There 
is  shght  pericorneal  injection,  and 
at  first  no  great  tendency  to  form 
synechiae.  It  is  not  uncommon  to 
find  the  tension  somewhat  higher 
than  normal,  at  least  in  the  earlier 
stages  of  the  disease;  later  it  di- 
minishes.    With  the  formation  of 

posterior  synechiae,  if  they  are  at  all  extensive,  secondary  glaucoma 
may  develop.  The  one  fairly  constant  clinical  sign,  which  in  a  certain 
sense  is  characteristic,  is  the  manifestation  which  gave  rise  to  the  name 
"punctate  keratitis" — namely,  a  deposit  of  variously  sized  and 
colored  dots,  arranged  usually  in  a  triangular  manner  on  the  posterior 
layer  of  the  cornea.  In  this  connection,  however,  it  should  not  be 
forgotten  that  this  so-called  descemetitis,  in  some  form  or  other  at 


Fig.  154. — Uveitis,  showing  punctate 
deposits  on  cornea  and  cross-hatching 
(magnified) . 


352  DISEASES  OF  CILIARY  BODY  AND  SYMPATHETIC  INFLAMMATION 

least,  is  practically  always  present  in  all  varieties  of  iridocyclitis,  al- 
though not  necessarily  in  the  trianp;ular-like  manner  which  has  just 
been  described.  The  deposits  on  the  posterior  surface  of  the  cornea 
may  be  fine  and  dust-like,  or  large  and  drop-liko.  Trt  the  last-named 
variet}'  the  term  "mutton-fat"  is  often  applied.  The  deeper  layers 
of  the  cornea  may  be  infiltrated  (keratitis  profunda;  see  also  page 
328),  and  the  iris  may  contain  thickenings  and  nodules,  especially 
in  the  tuberculous  types  of  the  disease. 

Not  only  are  the  evidences  of  involvement  of  the  iris  and  ciliary 
body  present,  but  in  most  cases  careful  examination  of  the  choroid  will 
reveal  lesions  in  its  tissues.  They  may  be  vague,  and  comprise  only 
the  so-called  choroidal  congestion,  or  appear  far  out  in  the  periphery 
in  patches  of  acute  choroiditis,  sometimes  in  large  zonular  areas  of 
acute  plastic  choroiditis,  and  sometimes  so  far  forward  that  ophthal- 
moscopic examination  does  not  reveal  their  presence.  The  vitreous 
usually  contains  fine,  floating  opacities,  or,  in  severe  cases,  coarse, 
web-like  opacities,  and  occasionally  hemorrhages.  The  visual  field 
examination  will  often  reveal,  even  in  the  absence  of  rise  of  tension, 
irregular  contractions,  and,  not  uncommonly  in  the  earlier  stages  of 
the  disease,  scotomas.  The  visual  acuteness  may  be  greatly  decreased, 
owing  to  exudations  in  the  vitreous  and  the  deposits  on  the  cornea, 
while  in  some  of  the  milder  cases  it  is  scarcely  reduced  below  the 
normal,  and  the  patients  are  conscious  onh'  of  ocular  disea.se  because 
of  slight  local  discomfort  and  muscse  in  their  field  of  vision. 

There  are  so  many  manifestations  of  this  disease  that  it  is  not  practic- 
able to  attempt  an  exact  classification.  In  general  terms,  it  may  be 
said  that  sometimes  the  signs  are  chiefly  those  of  punctate  keratitis 
or  descemetitis;  that  a  senile  form  of  the  disease  is  not  unconunon, 
unassociated  with  acute  symptoms  or  involvement  of  the  iris,  with 
only  a  few  spots  on  the  posterior  surface  of  the  cornea,  and  with  a 
certain  amount  of  flaky  vitreous  opacity,  choroitlitis  in  active  mani- 
festation being  absent,  although  there  may  be  a  certain  amount  of 
irregularity  of  the  retinal  circulation;  that  occasionally  a  marked 
descemetitis  is  the  chief  sign  of  a  decided  choroiditis  or  choroidoretinitis, 
often  of  obscure  origin;  that  a  chronic  uveitis  may  develoj)  in  the  iris, 
less  commonly  in  the  ciliary  body,  with  or  without  punctate  ileposits  in 
the  cornea,  insidious  in  character,  more  frecjuently  encountered  in  young 
women  than  in  men  or  in  diildren;  and  that,  finally,  the  disease  may  be  , 

recurrent  and  assume  a  type  to  which  the  author  has  ventured  to  give  ] 

the  name  7Ji(di(jnant  uveitis,  and  which  terminates  in  secoiidary  glaiieonia, 
cataract,  and  often  in  blindness. 

With  these  cases  of  malignant  uveitis  may  be  tl(>scribed  those  to 
which  the  names  iridochoroiditis,  cyclitis  with  disease  of  the  vitreotis  and 
keratitis  punctata,  and  chronic  serous  iridochoroidifis  iiave  been  given. 
They  have  in.'en  divided  inti)  two  forms,  according  as  the  affection  is 
primary  in  the  iris  or  in  the  choi-oid.  In  the  lirst  instance,  tiiere  are 
mild  iritis,  insignificant  pii'm,  and  ciliary  congestion,  dee))ening  of  the 
anterior  cliMmber,  and  sjjots  on  the  posterior  layer  of  the  cornea;  infiam- 


m'EITIS,    OR    SEROUS    CYCLITIS  353 

mation  continues,  relapses  take  place,  exudation  occurs  behind  the  iris, 
while  its  pupillary  margin  is  bound  down  so  that  the  surface  is  irregu- 
larly bulged  forward,  and  if  the  pupil  is  not  too  much  occluded,  the 
ophthahnoscope  will  reveal  many  floccuU  in  the  vitreous.  The  tension 
may  now  rise  and  the  ej-e  pass  into  secondary  glaucoma. 

In  the  other  type  the  process  passes  from  behind  forward,  beginning 
^\ath  patches  of  choroiditis,  which  increase  in  extent  and  depth;  the 
nutrition  of  the  vitreous  is  impaired  and  opacities  form,  the  lens  is 
altered  and  pushed  forward,  the  iris  becomes  embedded  in  a  plastic  in- 
flammation, with  narrowing  of  the  anterior  chamber  and  a  loss  of 
^^sion.  As  the  disease  of  the  uveal  tract  continues,  the  lens  becomes 
opaque,  the  ej'eball  softens,  the  retina  may  be  detached,  and,  finally, 
phthisis  bulbi  occurs.  In  addition  to  the  causes  already  mentioned, 
the  affection,  which  is  common  in  young  adults,  and  usually  symmetric, 
has  been  attributed  to  prolonged  work,  associated  with  loss  of  sleep 
and  defective  nutrition-conditions,  which,  however,  can  be  regarded 
only  as  contributor}^  in  the  sense  that  they  render  the  uveal  tract  more 
hable  to  a  toxic  influence. 

Pathology. — The  deposits  on  the  posterior  surface  of  the  cornea, 
which  are  so  conspicuous  a  symptom  of  this  disease,  and  which  have 
given  rise  to  the  name  punctate  keratitis,  may  be  very  fine  or  of  medium 
size,  and  sometimes  large  and  greasj'-looking,  in  which  circumstances 
they  are  known  in  England  as  ''mutton-fat  deposits."  They  are  de- 
rived chief!}'  from  the  ciliary  body,  as  Fuchs  originally  demonstrated, 
and  also,  in  lesser  degree,  from  the  iris.  An  exudation  of  lympho- 
cytes occurs  upon  the  surface  of  the  ciliary  body,  the  lymphocytes 
pass  into  the  anterior  chamber  and  are  precipitated  on  the  posterior 
surface  of  the  cornea  (Fuchs).  Their  cyclitic  origin  has  been  strongly' 
maintained  by  E.  Treacher  Collins,  especially  after  his  discovery  of  the 
so-called  glands  of  the  ciliary  body.  In  other  words,  according  to  him, 
this  disease  maj-  be  regarded  as  primarih'  a  catarrhal  inflammation  of 
these  glands.  Their  secretion,  he  maintains,  becomes  augmented, 
causing  increase  in  the  aqueous  humor  and  deepening  of  the  anterior 
chamber.  The  aqueous  is  altered  in  character,  contains  leukocytes, 
pigment  cells,  and  fibrin,  and  these  formed  elements  gravitate  and  are 
deposited  upon  the  lower  portion  of  the  posterior  face  of  the  cornea. 
Some  authors — for  example.  Hill  Griffith — have  asserted  that  the  dots 
on  Descemet's  membrane  are  formed  in  the  choroid  and  set  free  in  the 
vitreous,  are  carried  by  the  nutrient  currents  of  the  eye  and  deposited 
on  the  back  of  the  cornea.  His  view,  as  he  himself  points  out,  would 
necessitate  the  admission  that  the  suspensory  hgament  is  permeable  to 
solid  particles.  Histologic  investigation  of  the  eydo  affected  with  this 
disease  indicate  that  in  general  terms  there  is  a  chronic  cyclitis,  in  which 
the  anatomic  changes  do  not  materially  differ  from  those  found  in- 
ordinary types  of  cyclitis.  Groenouw  has  demonstrated  round-cel- 
led infiltration  of  the  iris,  of  the  deeper  layers  of  the  corneal  border  and  the 
cihary  body,  with  collections  of  round  cells  on  the  posterior  layer  of  the 
cornea  and  on  the  ciliary  processes.     In  his  investigations  the  choroid, 

23 


354     DISEASES  OF  CILIARY  BODY  AND  SYMPATHETIC  INFLAMMATION 

retina,  and  optic  nerve  were  normal,  but  other  observers  have  found 
them  affected,  as  necessarily'  would  be  the  case  in  so  far  as  the  choroid 
is  concerned,  where  the  ophthalmoscojjic  evidences  of  choroiditis  are 
present.  In  later  stages  of  chronic  uveitis  there  is  an  overgrowth  of 
the  epitheUum  of  the  ciharj'  body.  This  epithebal  h\'perplasia,  de- 
scribed by  Fuchs,  is,  according  to  him,  characteristic  of  some  cases  of 
chronic  uveitis.  Harms'  investigation  of  the  pathologic  anatomy  of 
chronic  iridocyclitis  with  deposits  on  Descemet's  membrane  indicates 
that  the  inflamniation  of  the  uveal  tract  is  limited  largely  to  the  anterior 
segment  of  the  eyeball,  the  deeper  parts  being  much  less  affected. 
The  pigment  found  in  the  deposits  on  the  posterior  surface  of  the  cornea 
arises  prol)ably  in  part  from  degenerated  red  corpuscles,  and  largely 
from  the  uveal  tract.  In  some  grave  types  of  iridocj'clitis,  leatling  to 
retinal  detachment  and  atrophy  of  the  eyeball,  Fuchs  found  lesions 
resembhng  exogenous  endophihahnitis,  and  believes  they  are  cau.sed 
by  a  virulent  toxin  or  by  bacteria  conveyed  by  metastasis. 

Treatment. — This  depends  upon  the  character  of  the  disease  or 
the  type  which  it  assumes.  In  the  absence  of  increased  intra-ocular 
tension,  mydriatics  are  indicated,  either  atropin  or  scopolamin.  With 
increased  tension  the  m5'driatic  must  be  suspended  and  occasionally 
a  miotic  may  be  needed,  or  paracentesis  of  the  anterior  chamber 
may  be  performed.  Dionin  is  of  distinct  advantage,  and  it  may  be 
combined  with  the  atropin  or  eserin,  according  to  indications.  Pilo- 
carpin  diaphoresis  is  sometimes  admirable  in  its  effects.  If  for  any 
reason  the  drug  is  not  well  borne,  a  similar  physiologic  action  may  be 
obtained  by  sweats  induced  in  a  Turkish  hath,  or  with  the  aid  of  an 
ordinary  cabinet.  Subconjunctival  injections  are  exceedingly  vahia  be 
— either  ordinary  physiologic  salt  solution  or  cyanid  of  mercury.     Mer-  _  — 

cury,  preferably  by  inunction,  even  in  non-specific  cases,  should  l)e  ex-  ■ 

hibited.  It  may  also  l)e  given  by  the  mouth  in  tlie  form  of  the  jirotiodid. 
In  syphilitic  cases  the  indications  for  meicury  are  evident, and .N'(//r(/r.s7;// 
and  neosalvarsan  or  their  equivalent — nrsphennmin  (seejiage  33'))  should 
be  employed.  lodid  of  potassium,  iodid  of  sodium,  iodid  of  lithium  and 
sajodin  are  important  alterative  remeilies,  and  in  acute  cases,  especially 
those  associated  with  great  (laiii  and  decided  cyditis,  full  iloses  of  sali- 
cylate of  sodium  or  of  aspirin  render  signal  service.  Naturally,  the 
indications  furnished  by  the  probable  etiologic  factors  must  be  given  due 
consideration,  and,  therefore,  iron,  arsenic,  Iwchlorid  of  mercury,  .syruj)  of 
hydriodic  acid,  and  similar  r(Mn(Mlies  should  be  administered.  \\  i(h 
atoxyl  in  tiiis  disease  the  autiioi'  has  had  no  experience,  but  he  has  seen 
marked  benefit  follow  the  adiiiiiiistration  of  Donovan's  solution.  The 
administration  (»f  tuberculin  in  the  m; inner  already  described  (se(»  page 
341)  is  followed  iiy  excellent  results,  and  should  certainly  have  full  trial 
if  the  reaction  to  tuheiculin  is  positive.  Alayou  has  su('ce.><sfully  treated 
uveitis  with  .sUipln/lorocric  /vfrr/z/c  where  the  sta])liylococcus  has  been  ob- 
tained from  tlie  anterior  chamber  by  paiacentesis.  and  tests  have 
demonstrated  that  neither  tuberculosis  nor  .sy])hilis  is  the  etiologic  factor. 
Indeed,   nirritie  ])re|);uc(|    from    ciiliuics  t;iken    from    the  area  of  focal 


UVEITIS,    OR   SEROUS   CYCLITIS  355 

sepsis  (from  the  tonsils,  etc.)  from  which  the  active  bacterial  element  is 
derived  have  been  used  with  great  advantage  and  are  well  worth  trial 
(see  also  page  339).  The  author's  investigations  as  well  as  those  of 
Elschnig  and  other  observers  indicate  that  in  a  certain  number  of  cases 
of  uveitis,  especially  of  an  insidious  and  relapsing  type,  so-called  ente- 
rogenous auto-intoxication  bears  a  relation  to  the  disease,  even  if  it  is  not 
a  causal  one  in  the  sense  that  a  toxin  formed  within  the  metabohsm  is  the 
exciting  agent,  and  treatment  should  include  a  carefully  selected  diet  and 
intestinal  antisepsis.  Indeed,  the  association  of  intestinal  sepsis  with 
this  disease  is  often  an  intimate  one.  Regulation  of  diet  alone  is  not 
sufficient,  although  indigestible  articles  of  food  should  be  forbidden, 
especialh'  sweets  and  carbohydrates.  T.  G.  Dwyer  has  elaborated  a 
method  of  treatment  which  consists  in  intestinal  irrigations,  notably 
anhydro-sodimn  carbonate,  and  making  implantation  of  the  colonhacillus 
and  restoring  the  normal  reaction  of  the  intestinal  contents.  The 
Bulgarian  bacillus  internally  is  of  value.  The  important  relation  of  focal 
infection  in  the  rhinopharynx,  the  tonsils,  the  teeth,  and  the  accessory 
sinuses  etc.,  to  this  affection  has  been  referred  to  (page  350),  and 
these  regions  should  be  thoroughly  explored  and  treatment  ordered 
according  to  the  findings.  The  removal  of  infected  tonsils,  the  extraction 
or  sterilization  of  septic  teeth  is  of  the  greatest  importance.  The  in- 
vestigation of  the  teeth  should  alwaj's  include  an  x-raj^  examination. 
As  Allen  J.  Smith  and  Barrett  have  found  that  the  Endavieba  buccalis 
is  one  of  the  factors  in  the  production  of  pyorrhoea  alveolaris,  emetin 
has  been  used  with  success  in  reheving  the  oral  sepsis,  and  thus  in- 
directly maj'  help  in  the  cure  of  a  uveitis  caused  bj'  it. 

After  the  acute  s\Tiiptoms  have  subsided,  in  the  opinion  of  some  au- 
thors massage  of  the  e3'eball  is  desu-able,  and  galvanism  has  been  advo- 
cated. S.  Lewis  Ziegler  beheves  that  electric  treatment  shortens  the 
course  of  uveitis.  He  advises  the  application  of  the  positive  pole.  In 
some  types  of  severe  uveitis  the  administration  of  th\Toid  extract  has 
achieved  encouraging  results  (Dunn,  Bordley). 

If  as  the  result  of  tliis  disease  firm  posterior  synechiae  block  the  com- 
munication between  the  anterior  and  posterior  chambers,  this  should 
be  reopened  by  a  broad  peripheral  iridectomy,  which,  if  the  lens  is 
opaque,  may  be  combined  with  its  extraction.  Even  in  eyes  in  which 
softening  has  begun,  provided  the  field  of  vision  still  remains  intact, 
good  results  will  sometimes  follow  a  successful  iridectomy.  If  at  anj' 
time  during  the  course  of  the  disease  rise  of  intra-ocular  tension  should 
develop  and  iridectomj'  should  not  be  admissible,  either  paracentesis  of 
the  anterior  chamber  or  posterior  sclerotomy  may  be  tried.  Tapping  the 
anterior  chamber  has  been  advised  as  a  therapeutic  measure,  even  if  the 
tension  is  not  elevated,  and  in  some  cases  in  which  the  author  has  put 
this  expedient  to  the  test  it  has  been  of  benefit  to  the  patients.  The 
fluid  from  the  chamber  should  be  examined  for  the  Spirochceta  pallida, 
tubercle  bacilH,  and  for  pyogenic  organisms.  From  the  latter  vaccines 
should  be  prepared  as  has  aheady  been  advocated. 

A  few  reports  indicate  that  radium  has  served  a  useful  purpose  in 


356    DISEASES  OF  CILIARY  BODY  AND  SYMPATHETIC  INFLAMMATION 


relieving   the   pain    and    facilitatinti    the   ab:?orption   of   inflammatory 
products  in  chronic  uveitis  (C.  H.  WilHams). 

Injuries  of  the  Ciliary  Body. — The  danjier  attending  perforating 
wounds  of  tlic  sclera   lias  hccii  described  on  pa^e  318,  this  danp;er  is 

doublv  increased  if  the  wound  occurs 


in  any  portion  of  a  zone, 


inch 


wide,  surrounding  the  cornea,  a  re- 
gion conunonly  called  the  "dangerous 
zone,"  after  the  late  Mr.  Xettleship's 
apt  description.  In  addition  to  the 
damage  inflicted  by  the  wound  the 
risk  of  acute  and  suppurative  cycHtis 
and  of  sympathetic  inflammation  is 
present. 

Treatment. — After  a  penetrating 
wound  in  this  region  two  courses  are 
open  to  the  surgeon — an  attempt  to 
save  the  ej-e,  or  immediate  enucle- 
ation. If  an  attempt  be  made  on 
the  side  of  con.scrv'atism,  the  plan 
discussed  under  scleral  wounds  (see  page  318)  should  be  followed;  if  not, 
enucleation  or  one  of  its  substitutes  will  be  refjuired  (see  page  709). 

Syphilis  of  the  Ciliary  Body. — Syphilitic  affections  of  the  ciliary 
bodv  may  exist  either  in  a  diffuse  infiltration  of  granulation  tissue  and 


Fig.    155.- 


-Gumma    of   iris   and   ciliary 
body. 


/■-''^ 

^■^.. 

/ 

■  ■  ■#' 

-^.•■yi,^- 

Flo.  156. — MioroBfopic  section  of  n'liiiimi  of  iris  and  ciliary  body  (see  Fiu.  155): 
I,  Remains  of  lens;  c.  />.  atropliied  ciliary  proi'cssi-B;  v>  KUinniatous  growth  involvins 
base  of  iris  and  ciliary  body,  r'ontainiiiK  in  its  center  a  cj'Sf,  r. 

inflamnialory  exudalioti   or   in  lunior  formation     that  is.  in  syphiloma 
of  (he  cilianj  hudj/,  to  adopt   the  term  advi.sed  by   lOwetzky,  who  ha.s 


TUMORS    OF    THE    CILIARY   BODY 


357 


thoroughly  studied  this  subject.  According  to  him,  the  symptoms  of 
syphiloma  of  the  ciliary  body  manifest  themselves  chiefly  in  the  form 
of  a  severe  iridocyclitis,  with  hazy  cornea,  or  an  intense  parenchyma- 
tous vascular  opacity  of  this  structure.  Keratitis  punctata  may  be  a 
prominent  symptom,  and  sometimes  hj'popyon  is  present.  The  tumor 
formation  in  the  ciliary  region  may  extend  completely  around  the 
cornea,  and  perforation  usually  takes  place  through  the  sclera  or  into 
the  anterior  chamber.  The  color  of  the  tumor  is  often  yellow,  and 
when  caseous  degeneration  sets  in  there  maj^  appear  in  the  anterior 
chamber  the  products  of  the  degeneration  of  the  tumor,  which  give  rise 
to  the  appearance  of  hypopyon.  The  largest  number  of  cases  occur 
between  the  twentieth  and  the  fortieth  years  of  life,  and  more  men  than 
women  are  affected.  Only  rarely  is  inherited  syphihs  a  cause  of  this 
condition.  In  those  cases  due  to  acquired  syphilis,  a  large  percentage 
has  appeared  in  the  early  stage  of  the  S3^stemic  affection. 

A  number  of  cases  of  gumma  of  the  ciliary  body  have  been  recorded, 
but  on  pathologic  grounds  it  is  probably  impossible  to  distinguish 
between  papules  and  gummas,  and,  therefore,  Ewetzky's  term  syphil- 
oma is  appropriate.  Some  writers  describe  precocious  gummas  of  the 
ciliary  body  as  early  tertiary  lesions,  but  Ewetzky  does  not  believe 
that  they  should  be  separated  into  a  special  group.  The  condition 
must  be  differentiated  from  syphilitic  growths  of  the  conjunctiva  which 
are  movable;  from  syphiloma  of  the  sclera,  which  is  usually  unas- 
sociated  with  iridocyclitis,  and  from 
melanotic  sarcoma  and  tuberculosis 
of  this  region.  The  treatment  does 
not  differ  from  that  which  has  been 
advised  in  connection  with  syphilitic 
diseases  of  the  iris,  and  full  doses  of 
mercury  and  iodid  of  potassium  are 
the  most  important  therapeutic  agents, 
especially  if  used  in  conjunction  with 
salvarsan  and  neosalvarsan  (see  page 
335). 

Tumors  of  the  Ciliary  Body. — 
Primary  sarcoma  of  the  ciliary  body 
is  a  rare  disease.  Usually  the  growth 
is  pigmented,  although  a  few  cases  of 
leukosarcoma  have  been  described. 
The  sarcoma  may  not  seriously  impair 
the  function  of  the  eye  in  its  earlier 
stages,  when  the  tumor  appears  as  a  brown  mass  behind  the  iris,  rarely 
in  the  angle  of  the  anterior  chamber.  Later  the  growth  exhibits  the 
four  stages  which  are  common  to  all  intra-ocular  tumors.  The  tumor 
may  be  composed  of  round,  spindle,  or  mixed  cells,  and,  according  to 
Groenouw,  the  prognosis  is  better  than  in  sarcoma  of  the  choroid. 
Sometimes  sarcoma  of  the  ciliary  body  assumes  a  flat  and  infiltrated 
character,  to  which  the  name  ring  or  annular  sarcoma  has  been  given. 


Fig.  157. — Pigmented  sarcoma  of 
ciliary  body  protruding  into  the  pupil 
space  (from  a  patient  in  the  University 
Hospital). 


358    DISEASES  OF  CILIARY  BODY  AND  SYMPATHETIC  INFLAMMATION 

This  is  a  comparatively  rare  manifestation,  only  about  8  cases  being 
on  record  (Ailing  and  A.  Knapp).  The  ciliary  body  may  also  be 
invaded  by  sarcoma  from  the  choroid  or  iris. 

Other  growths  which  have  been  noted  in  this  region  are  epithelial 
hyperplasias  and  innocent  tumors  of  the  ciliary  epithelium  (Fuchs), 
which,  occurring  in  elderly  persons,  arise  from  the  unpigmented  layer 
at  the  summit  of  a  ciliary  process.  An  unusual  pathologic  condition 
found  by  Fuchs  in  an  eyeball  atrophic  after  iridocyclitis  is  a  neuroma 
of  a  ciliary  nerve.  Adenomas  have  been  described  and,  very  rarely, 
primary  carcinoma,  myoma,  and  myosarcoma.  For  those  tumors 
of  the  ciliary  epithelium  which  represent  the  embryonic  retina  Fuchs 
proposes  the  name  diktyoma.  A  tumor  of  this  character  has  been 
described  by  Verhoeff  with  the  title  ieratoneuroma  emhryonale. 
Metastatic  carcinoma,  secondary  glioma  and  hypernephroma  have  been 
recorded. 

As  an  extension  of  the  disease  from  the  iris  or  choroid,  tubercle  of 
the  ciliary  body  may  appear,  and  leprosy  nodules  have  been  reported,  as 
have  also  a  few  cysts. 

Senile  degeneration  of  the  ciliary  body  occurs,  and  atrophic  changes  in 
this  structure  are  met  with  after  cyclitis.  AccorcUng  to  Parsons, 
calcification  and  ossification  of  the  ciliary  body  itself  are  rare.  Nearly 
always  they  are  sequels  of  ossification  in  the  choroid.  A  bony  gro^-th 
within  the  ciliary  body  has  been  reported  (H.  H.  Brown). 


SYMPATHETIC  IRRITATION   AND  SYMPATHETIC  INFLAMMATION  OR 

OPHTHALMITIS 

Sympathetic  Irritation  is  a  functional  disturbance  in  an  eye  pre- 
viously sound  by  virtue  of  injury  or  disease  of  the  fellow  eye,  probably 
due  to  irritation  of  the  trigeminal  branches.  It  presents  a  series  of 
symptoms,  comprising  photophobia,  lacrimation,  blepharospasm, 
defective  or  impaired  accommodation,  lessened  visual  acuteness, 
inability  to  perform  close  work,  neuralgic  pain  through  the  tlistribution 
of  the  supra-orbital  nerve,  tenderness  on  pressure  over  the  ciliary 
region,  photopsia,  contraction  of  the  field  of  vision  (fatigued  visual 
field),  and  hyperemia  of  the  eye-ground. 

Its  causes  are:  Injuries  of  the  eye,  foreign  bodies  in  the  cornea  and 
conjunctiva,  keratitis,  inflammations  of  the  uveal  trai-t.  luxation  of 
the  crystalline  lens,  ill-fitting  artificial  eye,  etc.  The  condition  may 
recur  and  in  this  sense  lasts  for  weeks  and  even  months.  It  tlisappears 
promptly  on  removal  of  the  exciting  cause.  It  does  not  pass  over 
into  synipatiictic  ophthalmia,  althougli  this  disease  is  sometimes 
ushered  in  by  initalive  plieiionieiia  analogous  to  those  just  tieserilxnl, 
wiiich,  rather  iinfortuiialely  are  also  often  denominated  "sympatlietic 
irritation." 

This  finictional  disturbance,  that  is,  sympatlietic  initation,  as 
(lesciil)ed,  siiould  l>e  definitely  separat(>d  from  sympatlietic  opli- 
thalmia  as  tliere  is  no  sound  evidence,  as  has  been  maintained  by  some 


SYMPATHETIC    INFLAMMATION  359 

writers,  that  its  origin  is  infective  and  that  the  character  of  its  mani- 
festations is  due  to  small  or  intermittent  doses  of  the  toxin. 

Sympathetic  Inflammation  {Sympathetic  Ophthalmitis;  Migra- 
tory ophthalmia  [Deutschmann];  Anaphylactic  Uveitis  [Elschnig]). — This 
is  an  iridocyclitis  of  one  eye  due  to  an  affection  of  similar  character  most 
often  caused  by  injury  in  the  fellow  eye.  It  is  customary  to  describe 
the  eye  which  is  implicated  as  the  result  of  disease  or  injury  of  its 
fellow  as  the  sympathizing  eye,  and  the  one  affected  by  the  disease 
or  injury  which  causes  the  irritation  or  inflammation  as  the  exciting 
eye. 

Conditions  Producing  Sympathetic  Inflammation. — Generally  one 
or  other  of  the  following  conditions  is  present: 

(1)  Wounds,  especially  of  the  ciHar}^  region  which  set  up  atraumatic 
iridoc3'clitis  or  uveitis,  especially  if  associated  with  prolapse  and  incar- 
ceration of  the  underlying  tissue  or  the  capsule  of  the  lens.  The  ciliary- 
region  is  the  zone  previously  described  by  the  term  borrowed  from  Mr. 
Nettleship,  "dangerous  zone."  Traumatisms  probably  cause  over 
80  per  cent,  of  the  cases  of  sympathetic  inflammation.  (2)  Foreign 
bodies  retained  in  the  eye  because  of  secondar}*  infection  or  infec- 
tion at  the  wound  of  entrance.  It  is  improbable  that  a  retained 
sterile  chemically  inert  foreign  body  will  cause  sympathetic  ophthalmia. 
(3)  Perforating  wounds  or  ulcers  of  the  cornea  in  which  the  iris  has 
become  incarcerated,  or  scars  involving  the  ciHary  bod}-.  (4)  Opera- 
tions upon  the  eye — extraction  of  cataract,  sclerotomy,  iridodesis,  iri- 
dectomy, discission,  and  reclination — followed  by  iridocyclitis.  (5) 
Intra-ocular  tumors,  e.  g.,  sarcomas  (Fuchs,  Meller),  if  associated  with 
iridocycUtis.  (6)  Ossification  and  calcification  of  the  choroid  and  cili- 
ary bodj^  and  luxation  of  the  lens;  doubtless  associated  with  iridocy- 
cHtis.  (7)  Incarceration  of  the  stump  of  the  optic  nerve  in  scar  tissue 
after  the  operation  of  enucleation;  evisceration  of  the  eye  with  rem- 
nants of  uveal  tissue  remaining  attached  to  the  sclera  and,  in  rare  in- 
stances, implantation  of  an  artificial  vitreous  in  Tenon's  capsule  or  in 
the  scleral  cup  (Mules'  operation).^ 

There  is  no  sound  evidence  that  herpes  zoster  ophthalmicus, 
glaucoma,  symblepharon,  intra-ocular  cysticercus,  subconjunctival  rup- 
ture of  the  globe  (without  associated  iridocycUtis),  or  spontaneous  in- 
flammation of  one  eye  can  cause  sympathetic  ophthalmitis,  although 
sympathetic  irritation  may  arise  in  consequence  of  anj'  of  these  con- 
ditions (Schirmer).  Subconjunctival  rupture  of  the  sclera,  with  or 
without  luxation  of  the  lens  is  said  to  have  produced  sj'^mpathetic  oph- 
thalmia. JVIeller  has  reported  some  cases  of  sympathetic  ophthalmia; 
the  exciting  eye  having  acquired  inflammation  spontaneously,  that  is, 
without  injury,  but  in  each  instance  iridectomy  had  been  performed 
on  the  eye  originally  attacked.  E3^es  which  are,  or  have  been,  the 
subjects  of  purulent  panophthalmitis  very  rarely  produce  sympathetic 

^  It  is  possible  that  in  some  of  these  cases  enucleation  or  its  substitutes  may 
have  been  performed  when  the  sympathetic  inflammation  was  alreadj'  present  in 
its  earliest  stage. 


360    DISEASES  OF  CILIARY  BODY  AND  SYMPATHETIC  INFLAMMATION 

inflammation.  This  relationship  has  boon  rocordoci  (Alt,^  Schirmer. 
Ahlstrom,  Zontmayor).  Accordinj;  to  Rnjro,  oven  in  such  oyos  tho  roal 
exciting  causo  is  a  fihrinoplaslic  iiiHanimation. 

Varieties  and  Manifestations  of  Sympathetic  Inflammation. 
— -Sympatlietic  o])hthahuia  occurs  in  several  forms,  sonu'times  aiisinj: 
in  the  wake  of  an  attack  of  irritation,  but  frequently  without  any  pro- 
monition  or  association  of  this  character.  It  has  Ixhmi  stated  that 
marked  oscillation  of  the  iris  often  occurs  when  irritative  phenomena 
are  about  to  give  place  to  an  inflammation.  Disturbance  of  vision 
is  an  early,  if  not  the  earliest  subjective  symptom  of  sympathetic 
ophthalmia,  cominp;  on  in  advance  of  the  objective  signs  but  soon  is 
followed  by  pericorneal  injection,  spots  on  Descomet's  membrane,  etc. 

According  to  a  classification  adoi)ted  In'  many  systematic  writers 
sympathetic  ophthalmia  or,  as  it  may  be  called,  sympathetic  or  infective 
uveitis,  becau.se  tho  uveal  tract  is  especially  involved,  presents  it.self : 

1.  As  an  iridocijclitis  (uveitis  fibrinosa  sympathetica,  Schirmor), 
plastic  or  maliuiiant — /.  e.,  an  inflammation  characterized  by  ))ain.  pho- 
tophobia, pericorneal  congestion,  discoloration  of  the  iris,  closure  of 
the  pupil  by  exudation  around  its  margin  and  behind  tho  iris,  which  is 
plastered  to  the  capsule  of  the  lens,  cyclitis.  precipitates  on  the  po.s- 
terior  layer  of  the  cornea,  narrowing  of  the  ant(M-ioi'  chamber.  ofTusion 
into  the  vitreous,  involvement  of  thechoroid.opacityofthelens, detach- 
ment of  the  retina,  and  finally  shrinking  of  the  eyeball. 

2.  As  a  serous  iritis,  more  accurately  a  serous  iridocyclitis  (Panas). 
or  serous  iridochoroiditis  (do  Wecker),  or  serous  sympathetic  uveitis 
(Schirmor),  causing  tuibidity  of  the  aqueous,  deepening  of  the  anterior 
chamber,  ])unctate  opacities  on  tho  posterior  layer  of  the  cornea,  slight 
rise  in  tension,  moderate  ciliary  injection,  opacity  in  the  anterior  layers 
of  the  vitreous,  some  involvement  of  the  ciliary  body  and  choroid. 
Not  infi-o(|uontly.  if  not  in  all  the  cases,  papilloretinitis  coexists  with  the 
uveitis.  This  i)i-ocoss  under  proper  treatment  may  coa.-^e  and  recovery 
result;  but  often  it  may  pass  into,  or  be  the  forerunner  of.  a  malignant 
uveitis,  with  all  its  evil  consequences. 

Papilloretinitis  {sympathetic  papilloretinitis,  Schirmor),  as  a  coexist- 
ing condition  in  sympathetic  ophthalmia  has  been  noted.  How 
fre(iuent  this  association  is  it  would  l)o  practically  impossible  to  state 
because  of  the  difficulty  of  making  ophthalmoscopic  examination  in 
many  cases.  Rarely,  according  to  Schirmor,  it  constitutes  tho  primary 
affect  ion;  that  is,  tho  uvea  is  not  associated  in  tho  inflanunation.  This 
papillitis  usually  is  of  moderate  grade,  tho  disk  is  not  prominent,  its 
borders  are  veiled  and  surrounded  by  grayish  retinal  opacity;  tho  veins 
are  swollen  and  tortuous,  ami  ot-casionally  small  luMuorrhagos  are 
present.     Occasionally  the  swollen  tlisk  in  very  prominent,  in  one  case 

'  It  is  stated  tliiit  eyes  whicli  are,  or  li.ave  ht-cri,  tin-  sul)jffts  of  punileiif  pair 
oplitlialiiiitis  do  not  excite  sympatlietic  oplitluduiitis.  jiiid  ^eiifrally  in  suppiini- 
tioii  of  tlie  cornea  and  its  seipiels  and  in  paiioplitli.-dniitis  .and  tlie  phthisis  Ixditi 
wliich  it  causes,  this  complication  is  not  to  he  .apprehended  (I'uchsK  .Alt,  how- 
ever, in  his  !inal.\"sis  of  mor«>  th.an  100  cjiscs.  found  Li  eyes  enucle.ated  for  s\in- 
|)atlietic  iri<loclioroiditis,  the  oIIht  having  hecn  lo>l  l>y  purulent  panophth.almitis. 


SYMPATHETIC    INFLAMMATION  361 

studied  by  the  author  the  appearances  were  those  of  high  grade  choked 
disk. 

A  choroiditis  caused  by  sympathetic  inflammation  originally  re- 
corded by  von  Graefe  has  been  described  a  number  of  times,  notably 
by  Hirschberg,  Caspar,  Haab,  and  A.  Dalen.  The  lesions  somewhat 
resemble  the  spots  of  disseminated  choroiditis  due  to  syphilis,  and 
appear,  especially  in  the  periphery  of  the  eye-ground,  in  the  form  of 
small  yellowish-red  areas, "  with  central  pigment  dots.  According  to 
Dalen.  the  disease  is  a  chorioretinitis,  and  not  a  pure  choroiditis.  A 
peculiar  distribution  of  small  yellowish-white  flecks  or  nodes,  lying 
behind  the  retinal  vessels,  often  grouped  and  without  pigmentation, 
has  been  described;  they  probably  lie  within  the  choroid.  Choroiditis 
in  the  primarily  affected  eye  has  been  recorded  (Hirschberg,  Heerfordt). 

Other  manifestations  of  sympathetic  ophthalmitis  have  been  re- 
ported, for  example,  a  simple  atrophy  of  the  optic  nerve,  but  the  exact 
relationship  of  such  a  condition  to  a  sympathetic  affection  has  not  been 
proved.  In  this  connection  reference  should  be  made  to  the  so-called 
sympathetic  amblyopia  described  by  Nuel,  which,  according  to  this 
author,  begins  at  a  much  later  period  than  true  sympathetic  ophthal- 
mia— that  is,  at  a  period  later  than  one  or  two  months  after  the  trau- 
matic iridocyclitis  has  occurred.  At  first  there  is  only  a  vague 
amblyopia,  with  obscurations;  later  visual  acuteness  is  much  reduced 
and  the  field  of  vision  contracted,  and  should  the  amblyopia  attain 
a  decided  degree,  there  may  be  a  slight  neuritis  or  pallor  of  the  papil- 
lomacular  bundle,  or  a  perivasculitis.  The  affection  may  continue  for 
months  or  even  years,  with  alternate  improvements  and  aggrava- 
tions. Xuel  explains  it  by  assuming  the  presence  of  a  neuritis  caused 
by  a  hyperplasia  of  the  interstitial  tissues. 

Premonitory  Symptoms. — These  are  of  great  importance.  One  fre- 
quently described  is  tenderness  in  the  ciliary  region,  frequently  in  a 
circumscribed  spot,  which  may  be  picked  out  with  the  end  of  a  probe. 
When  this  is  pressed  upon,  the  patient  shrinks  from  the  touch  in  a 
peculiar  and  striking  manner.  Sometimes  an  exactly  similar  tender 
spot  is  found  in  the  ciliary  region  of  the  exciting  eye.  Biehler  and  E.  von 
Hippel  have  demonstrated  that  fluorescein  will  color  the  endothelium 
of  the  cornea  in  certain  uveitic  inflammations  when  the  superficial 
layers  of  the  cornea  are  still  intact  and  when  ordinary  examination  fails 
to  reveal  these  early  changes.  Alberti  suggests  the  use  of  this  test  in 
cases  of  suspected  but  not  yet  manifest  sympathetic  inflammation. 
A.  Maitland  Ramsaj'  and  A.  W.  M.  Sutherland  have  observed,  using 
Bjerrum's  method  (see  page  82),  spindle-shaped  enlargement  of  the 
blind-spot  as  a  sign  of  active  congestion  of  the  optic  disk,  and  suggest 
this  examination  as  an  important  aid  in  determining  the  onset  of  trouble 
passing  from  an  eye  with  an  infected  injury  to  the  fellow  eye.  E.  von 
Hippel  has  applied  Abderhalden's  test  in  cases  of  sympathetic  ophthal- 
mia; in  these  patients  a  positive  biologic  reaction  to  uveal  tissue  was 
obtained,  but  the  reaction  is  not  specific  for  sympathetic  ophthalmitis. 

The  general  symptoms  of  this  condition  are  of  importance.     The 


362    DISEASES  OF  CILIARY  BODY  AND  SYMPATHETIC  INFLAMMATION 

presence  of  meningitis  has  been  suspected,  but  never  demonstrated. 
Severe  headache,  however,  rise  of  temperature,  doHrium,  and  deafness 
have  been  reported,  and  it  is  of  the  utmost  importance  to  submit 
patients  who  are  sufferinfj;  from  symjiathctic  ophthahnitis  to  the  fullest 
investigation  from  the  general  standpoint.  H.  8.  Gradle's  investiga- 
tions indicate  that  marked  lymphocytosis  is  likelj'  to  be  present  if  an 
injured  eye  is  of  such  character  that  it  may  produce  sympathetic  oph- 
thalmia. The  diagnostic  and  prognostic  values  of  the  test  has 
been  disputed  by  a  number  of  observers.  S.  Gifford,  for  example, 
doubts  if  "mononucleosis"  is  specific  for  sympathetic  ophthalmia; 
it  represents,  according  to  him,  a  reaction  of  the  body  to  an  intlamma- 
toiy  process  in  the  ej'e.  Gradle's  own  estimate  is  that  while  it  would 
not  be  safe  to  rely  upon  the  blood  count  in  deciding  whether  or  not  to 
enucleate  an  eye,  the  presence  or  absence  of  mononucleosis  should  be 
taken  into  account  in  doubtful  cases.  The  blood  should  be  examined 
for  micro-organisms  . 

Period  of  Incubation. — The  prodromal  symptoms,  in  so  far  as  the 
sympathizing  eye  is  concerned  have  been  tlescribed.  Although  the  excit- 
ing eye  usually  presents  marked  iridocyclitis  there  are  no  phenomena 
which  may  be  designated  as  pathognomonic.  Based  on  the  experience  of 
the  past  war  and  this  applies  also  to  the  accidents  in  civilian  life,  in  general 
terms  sympathetic  ophthalmia  is  likely,  to  occur  if  a  plastic  uveitis 
(iridocyclitis)  arises  as  the  result  of  a  penetrating  wound  of  the  cornea 
or  sclera,  especially  in  the  "danger  zone,"  associated  with  prolapse  of 
uveal  tissue  or  lens  capsule.  Persistent  cyclitis  or  uveitis  with  gradual 
and  increasing  lowering  of  intra-ocular  tension  and  of  vision  antl  with 
photophobia  of  the  fellow  eye  are  signals  of  grave  danger  demanding 
enucleation  of  the  originally  injured  eye. 

The  minimum  time  which  elapses  between  the  incitlence  of  the 
injury  and  the  development  of  sympathetic  ophthalmia,  save  only  in 
rare  instances,  is  fourteen  days;  it  must  be  feared  during  the  first  twelve 
weeks  after  the  injury,  especially  between  the  sixth  and  the  twelfth 
weeks;  it  is  exceptional  after  this  period,  that  is,  after  the  third  month. 
Exceptions  to  this  general  statement  are:  its  reported  incidence  jis 
early  as  the  ninth  day  and  its  postponement  as  late  as  twenty  years 
and  even  longer. 

Frequency. — The  proportion  of  sympathetic  ophthalmia  to  all 
ocular  alfections,  that  is  its  relative  frecpiency  has  been  variously 
stated  (0.134  per  cent,  by  Mooren,  0.15  per  cent,  by  Beck(>r).  So  also 
the  proportion  of  sympathetic  oi)hthalmia  io  severe  jienet rating  ocular 
wounds  has  been  variously  estimated  and  is  j)robably  l)etween  2  and  W.h 
per  cent.,  but  it  is  not  j)ossil)le  to  be  exact  in  this  regaril.  Among  those 
whose  occupations  do  not  expose  tluMn  to  (>ve  accidents,  children 
are  more  freciuently  affected  than  adults.  Sympathetic  o|)hthalmia,  in 
spite  of  the  numerous  penetrating  ocular  injuries  wliicli  tlie  past  war 
furnished  was  unconunon  as  compared  witii  its  repiuted  frequtMicy 
during  our  own  Civil  War  and  during  1  he  J'ranco-Prussian  War  of  1870. 

]'\)ur  factors  were  j)otent  in  ic(huing  to  a  gratifying  minimiuu  tiu^ 


SYMPATHETIC    INFLAMMATION 


363 


incidence  of  sympathetic  ophthalmia:  (1)  Accurate  recognition  of 
eyes  so  injured  and  inflamed  that  they  should  be  sentenced  to  prompt 
excision;  (2)  proper  early  treatment  of  injured  eyes;  (3)  the  healthy 
general  condition  of  most  of  the  soldiers;  (4)  abstinence  from  unneces- 
sary minor  operative  procedures. 

Pathologic  Anatomy. — The  pathologic  anatomy  of  eyes  which 
produce  sj-mpathetic  ophthalmitis,  that  is  to  saj',  exciting  ej-es,  has 
been  thoroughly  investigated,  while  that  of  the  ej'es  which  have  become 
inflamed  as  the  result  of  an  infective  cychtis  of  the  fellow  eye,  that  is, 
sympathizing  eyes,  has  not  received  much  attention,  for  the  simple 


Fig.   158. — Traumatic  iridocyclitis.     Diffuse  infiltration  of  the  iris  and  ciliary  body. 

reason  that  the  opportunities  of  examination  are  rare.  In  so  far,  how- 
ever, as  they  have  gone,  in  general  terms  it  may  be  stated  that  the 
lesions  are  identical;  in  other  words,  the  same  conditions  are  present  in 
the  exciting  and  the  sjinpathizing  eye. 

Schirmer  has  summarized  the  lesions  in  uveitis  which  produce 
sj-mpathetic  ophthalmitis  somewhat  as  follows:  All  three  portions  of 
the  uvea  contain  disseminated  foci  of  small  round  cells,  associated 
with  a  high  grade  of  inflammation,  characterized  by  a  diffuse  infiltration 
of  the  entire  tissue  with  similar  small  cells.  After  the  disappearance 
of  the  inflammation  the  uveal  structure  is  destroyed  and  atrophied, 
and  substituted  by  a  pigmented  connective  tissue  poor  in  vessels. 
Upon  the  surface  of  the  iris  and  ciliarj^  body  there  is  a  rich  fibrinous 
exudation,  with  a  strong  tendency  to  organization,  but  the  choroid 
fails  to  exhibit  a  similar  exudative  process. 

Fuchs'  investigations  have  thrown  a  new  Ught  on  the  pathologic 
anatomy  of  sympathetic   ophthalmitis.     He  found  in  the  uvea  of 


364    DISEASES  OF  CILIARY  BODY  AND  SYMPATHETIC  INFLAMMATION 

exciting  eyes  a  dense  infiltration  of  Ijanphocytes,  and  in  many  cases 
in  the  midst  of  this  infiltration  collections  of  epithelioid  cells,  often 
with  giant  cells  between  them.  This  infiltration  may  l)e  present  only 
in  certain  spots  in  the  form  of  isolated  nodules  in  the  iris,  ciliary  Imdy, 
or  choroid,  or  the  uvea  may  be  wholly  or  at  least  largely  occupied  by 
the  process.  Indeed,  the  infiltration  may  make  its  way  into  the 
sclera,  which  becomes  permeated  with  scattered  nodules.  In  so  far 
as  the  different  tissues  of  the  eye  are  concerned  and  their  implication 
in  this  process,  the  iris  is  the  least  affected,  the  ciliary  body  is  always 
involved,  and  usually  the  choroid  is  more  infiltrated  than  other  portions 
of  the  uvea,  especially  in  its  posterior  portion.  A  fibrinoplastic  uveitis 
not  infrccpiently  complicates  this  proliferative  uveitis  of  sympathetic 
inflammation,  but  Fuchs  does  not  regard  this  as  an  essential  factor  in 
the  process,  because  it  may  be  absent  in  typical  cases.  Bacteria  wore 
not  demonstrated  in  the  nodules,  but  Fuchs  does  not  doubt  that  the 
affection  is  produced  by  bacteria,  which,  instead  of  causing  an  acute 
suppuration,  originate  a  chronic  proliferation,  and  this  inflammation 
has  the  property  of  l)eing  transmitted  to  the  second  eye  througli  the 
circulation. 

Fuchs'  observations  have  been  confirmetl  by  Lenz,  Kitamura,  E.  V. 
L.  Brown,  and  a  number  of  other  observers.  Ruge,  however,  denies 
that  the  anatomic  conditions  found  in  an  eye  exciting  sym])athetic 
ophthahnitis  are  characteristic,  and  while  he  does  not  doubt  tliat  there 
is  a  mixed  infection  in  many  cases,  he  hokls  to  Schirmer's  view  that 
there  is  a  pure  sympathetic  plastic  exudation.  Meller  concludes  that 
such  marked  specific  changes  cannot  always  be  founil  in  the  exciting 
eye  as  would  justify  a  diagnosis,  but  such  insufficiency  of  histologic 
findings  does  not  alter  the  view  that  there  is  in  the  first  eye  a  specific 
morbid  process  similar  to  that  by  which  the  ophthalmia  of  the  second 
eye  is  produced  and  which  is  distinctly  different  from  posttraumatic 
inflammations.  Now,  while  it  may  l)e  too  much  to  say  that  jMolifera- 
tive  uveitis  is  pathognomonic  of  sympathetic  ophthahnitis.  there 
seems  no  doubt,  to  use  the  language  of  E.  V,  L.  Brown,  that  it  is  the 
essential  anatomic  condition  ])resent  in  the  eye  which  causes  sympa- 
thetic iiiflaiiiiiiation  of  its  fellow. 

Pathogenesis  of  Sympathetic  Ophthalmitis.  Formerly  it  was 
almost  universally  thought  that  this  disease  was  due  to  a  reflex  action 
through  the  ciliary  nerves,  and  on  this  theory  the  n;ime  "sym])athetic" 
was  api)hed.  The  exact  nature  of  this  grave  malady  is  not  known, 
althougli  tlie  oldei'  liypotiieses  ha\'e  iai'gely  l)een  ;il)andone(l  t"oi-  the 
theory  of  infection. 

According  to  Deutschmann,  the  inflammation  is  a  progressive  proc- 
ess in  tlu>  contiiniity  of  the  tissue  of  one  eye  to  the  other  l)y  way  of  the 
optic  riei\'c  ai)])arat  us,  and  is  of  l)acterial  origin;  hence,  a  nnijrotonj 
opfilliabnitis.  I  )cntschniann's  icscaiches  have,  however,  not  been 
confirmed  ((iifford,  .Mazza,  l{an<lol|>h,  Linibourg,  bevy,  and  (Jreeff). 
Isomer's  investigations,  ha\-e  utleil\-  set  aside  the  possibility  of 
accei)ling   the   ciliary   ner\'e    tlieoiy    in   :i?i\-   foitn.      HclK'U'ininolV  ;ind 


SYMPATHETIC    INFLAMMATION  365 

Selenkowskj^  believe  that  all  cases  of  s^-mpathetic  disease  may  be 
explained  by  the  action  of  a  toxin  which  is  produced  by  the  bacteria 
which  have  entered  the  primarily  affected  eye,  and  which  reach  the 
other  eye  by  means  of  the  lymph  and  diffusion  streams.  Brown 
Pusey  suggests  as  an  explanation  of  sympathetic  ophthalmitis  that 
the  cells  of  the  injured  eye,  probabh'  those  of  the  ciharj'  bodj-  and 
iris,  give  rise  to  a  cytotoxin,  which,  having  a  selective  affinity  for  corre- 
sponding cells  in  the  other  eye,  there  sets  up  an  inflammation.  A 
precisely  similar  theor}'  has  been  propounded  bj'  Golovine.  Motais, 
although  frankly  stating  that  he  has  no  clinical  evidence  to  support 
him,  and  that  as  3^et  no  experimental  researches  are  at  hand  to  lend  aid 
to  his  hypothesis,  maintains  that  the  anastomoses  between  the  veins 
of  exit  of  the  ej'es  constitute  the  most  probable  paths  for  the  trans- 
mission of  sympathetic  ophthalmitis;  and  even  so  great  an  authority 
as  Leber  believed  that  this  view  should  receive  consideration.  Romer 
regards  sympathetic  ophthalmitis  as  a  metastasis,  the  metastatic 
infection  proceeding  by  way  of  the  blood-streams,  and  thus  brings 
himself  in  accord  with  views  originally  expressed  by  Berlin.  This 
infection  is  ascribed  to  some  form  of  micro-organism  which  is  patho- 
genic for  the  eye  alone  and  does  not  afifect  the  body  generally.  The 
metastasis  theory,  according  to  Homer,  most  satisfactorih'  explains 
all  of  the  phenomena  of  so-called  s^mipathetic  ophthalmitis,  and  is 
entirely  consistent  with  the  result  of  modern  bacteriologic  research. 
Moreover,  it  has  now  received  confirmation  from  the  anatomic  stand- 
point, especially  by  Fuchs'  researches. 

The  micro-organisms  which  excite  sympathetic  ophthalmitis  have 
not  been  identified;  indeed,  they  have  not  been  seen,  and,  therefore,  it 
may  be  assumed  that  they  are  distributed  in  invisible  form  by  the  in- 
tra-ocular  fluids  throughout  the  eye,  to  which  they  have  been  trans- 
mitted by  the  blood-streams. 

While  the  prevailing  theory  is  that  in  sympathetic  ophthalmia  the 
infection  enters  the  eye  through  a  wound  or  other  pathway,  J.  ^leller 
has  advanced  an  endogenous  theory.  According  to  him  some  part  of  the 
body  other  than  the  eye  is  the  port  of  entry  for  the  specific  organism 
which  has  an  elective  affinity  for  uveal  tissue,  and  attacks  that  of  the 
diseased  eye  because  its  resistance  is  lowered,  the  damage  having  oc- 
curred from  a  wound  or  a  toxic  iridocyclitis.  Gradually  sympathetic 
inflammation  arises,  which  leads  to  metastasis  to  the  other  eye.  E. 
V.  L.  Brown  believes  that  this  theory  explains  those  cases  in  which  in 
the  primary  eye  neither  wound  nor  other  opening  can  be  found. 

Recently  Elschnig  has  maintained  that  in  the  development  of 
sympathetic  ophthalmia  two  factors  are  necessary:  anaphylaxis  of 
uvea,  on  account  of  tissue  disintegration,  the  chief  role  being  taken  by 
the  pigment,  and  an  anomalous  condition  of  the  organism,  for  example, 
nephritis,  diabetes,  auto-intoxication,  etc.  Xaturalh^,  this  theory  of 
the  existence  of  anaphylactic  uveitis  has  met  with  much  opposition,  but 
recently  has  acquired  some  advocates,  for  instance,  A.  Jess,  who  admits 
it  explains  certain  clinical  facts  better  than  the  bacterial  hypothesis, 


366    DISEASES  OF  CILIARY  BODY  AND  SYMPATHETIC  INFLAMMATION 

to  wit,  the  period  of  incubation,  and  Cramer,  who  observed  a  second 
attack  of  sj'mpathetic  ophthalmia  coincident  with  alopecia  and  whiten- 
ing of  the  eyebrows.  This  he  beUeved  was  an  anaphylactic  reaction  of 
pigment  origin.  Elschnig's  theory  has  been  tested  by  experiments  on 
animals  and  Alan  C.  Woods  has  produced  anaphylactic  iridocyclitis 
in  dogs,  but  admits  that  the  final  proof  of  the  theory  is  not  at  hand 
and  must  be  established  in  human  beings.  Thus  far  the  clinical 
features  of  sympathetic  ophthalmia  have  not  been  brought  into  accord 
with  what  Schieck  calls  the  "essence  of  anaphylaxis." 

Treatment. — The  most  important  consideration  is  prophylaxis,  or, 
in  other  words,  the  management  of  the  eye  originally  affected.  This 
depends  upon  the  character  and  situation  of  the  wound  or  upon  the 
stage  of  the  disease,  and  upon  the  amount  of  vision  possessed  by  the 
injured  or  diseased  organ. 

In  the  section  devoted  to  Treatment  of  Wounds  of  the  Sclera  (see 
page  318)  the  method  is  described  by  which  eyes  seriously  wounded 
may  be  saved.  Schirmer  believes  that  the  treatment  of  injured  eyes 
should  include  full  doses  of  mercury,  and  the  author  can  confirm  the 
therapeutic  value  of  this  remedy  in  this  respect,  as  well  as  the  value  of 
large  doses  of  salicylate  of  sodium. 

Where  every  advantage  of  nursing  and  careful  watching  is  at  hand, 
eyes  may  be  saved  which  would  be  sacrificed  in  other  circumstances. 
The  propriety  of  operating  may  be  determined  by  regarding  the  follow- 
ing rules,  which  are  modified  from  those  given  by  Schirmer  and  Swanzy, 
and  represent  the  published  experiences  of  the  best  authorities. 

Enucleation  should  be  performed  on — 

1.  An  eye  with  a  wound  so  situated  as  to  involve  the  ciliary  region, 
and  so  extensive  as  to  destroy  sight  inuuediately,  or  to  make  its  ulti- 
mate destruction  b}'-  inflammation  of  the  iris  and  ciliary  body  reason- 
ably certain. 

2.  An  eye  with  a  wound  in  this  region  already  complicated  by 
severe  inflammation  o  the  iris  or  ciliary  body,  even  if  sight  is  not  de- 
stroyed; or  an  eye  containing  a  foreign  body  which  judicious  etTorts 
have  failed  to  extract,  and  in  which  severe  iridocyclitis  is  present,  even 
if  sight  is  not  destroyed. 

3.  An  eye  the  vision  of  which  has  been  destroyed  by  plastic  iridocy- 
clitis, or  one  which  has  atrophied  or  shrunken,  providtnl  there  are 
tend(;rness  on  pressure  in  the  ciliary  region  and  attacks  of  recurring 
irritation;  or  without  waiting  for  signs  of  irritation. 

4.  An  eye  the  sight  of  which  has  been  destroyed,  even  though 
inflammation  has  begun  in  the  sympathizing  eye.  bi'cause  by  this 
means  a  source  of  additional  infection  is  removed,  and  the  treatment 
of  the  second  eye  is  rendered  more  effectual. 

5.  An  eye  in  which  the  wound  has  severely  involvi'd  the  cornea, 
iris,  or  ciliary  region,  the  fellow  eye  being  in  a  state  of  persisting 
irrit.'ibilify  or  subject  to  fre(iuen(  attiicks  of  so-c.-illed  synijiathetic 
irrilalioii. 

(i.   .\n  eye  either  piini;iiily  lost  by  injury  or  in  a  stale  of  atrophy, 


SYMPATHETIC    INFLAMMATION  367 

associated  with  signs  of  so-called  sympathetic  irritation  in  the  fellow 
eye  (see  also  page  358). 

It  is  universally  conceded  that  the  enucleation  of  an  eye  (preventive 
enucleation)  primarily  injured,  the  visual  function  of  which  cannot  be 
restored,  is  the  surest  way  of  preventing  sympathetic  ophthalmitis. 
It  is  to  be  remembered,  however,  that  even  a  very  early  enucleation 
does  not  necessarily  prevent  sympathy  in  the  fellow  eye,  because  the 
infective  process  may  have  begun  before  the  operation,  and  may  not 
develop  for  several  weeks.  It  has  occurred  fifty-three  days  after  the 
enucleation  of  an  eye  injured  twenty  days  prior  to  its  removal  (Ste- 
phenson), and  C.  B.  Welton  has  collected  28  cases  of  this  character,  the 
shortest  interval  between  the  injury  and  the  enucleation  being  nine 
days  and  the  longest  two  months.  In  place  of  enucleation,  eviscera- 
tion has  been  practised,  but  this  operation  has  been  followed  by 
sympathetic  inflammation.  Resection  of  the  optic  nerve  (neurec- 
tomy) does  not  provide  absolute  security;  enucleation  is  the  only 
satisfactory  procedure. 

If  sympathetic  inflammation  has  begun,  the  rules  just  quoted  are 
not  applicable,  and  enucleation  7nust  not  he  'performed  if  there  is  any 
vision  in  the  exciting  eye,  which  in  the  end  may  prove  to  be  the  more 
useful  organ.  The  treatment  already  recommended  for  iritis  and 
iridocyclitis  is  appropriate. 

In  the  treatment  of  the  sympathetically  affected  eye  operation 
usually  has  no  place.  Both  iridectomy  and  sclerotomy  have  been  ad- 
vised, but  it  is  better  to  await  the  subsidence  of  acute  symptoms  before 
attempting  any  surgical  interference  unless  the  intra-ocular  tension  is 
inordinately  raised,  when  scleral  incision  may  be  practised  or  iridec- 
tomy with  or  without  the  removal  of  the  lens. 

The  general  treatment  consists  in  confinement  in  a  darkened  room 
(moderate  exercise  with  eyes  well  protected  is  permissible  in  subjects 
failing  for  lack  of  it) ;  complete  functional  rest  of  the  eyes  and  atropin 
or  scopolamin  locally,  provided  there  is  no  rise  of  tension  and  no 
atropin  irritation;  and  leeches  to  the  temple  if  the  inflammation  is 
florid.  Dionin  (5  per  cent.)  should  be  used.  Mercurial  inunctions  are 
important,  and  free  diaphoresis,  either  with  pilocarpin  or  by  vapor 
baths,  has  been  advised;  in  debilitated  patients  tonics  and  alteratives 
are  advisable.  The  value  of  sodium  salicylate,  advocated  by  Gifford 
in  the  treatment  of  sympathetic  ophthalmitis,  is  great,  at  least  60  to 
100  grains  (3.9-6.5  gm.)  a  day  should  be  exhibited,  and  even  larger 
doses  are  sometimes  well  borne;  but,  inasmuch  as  the  treatment  must 
continue  for  long  periods  of  time,  the  doses  must  be  regulated  strictly 
according  to  the  results  achieved.  Gifford  believes  that  most  patients 
will  be  able  to  take  daily  1  grain  (0.065  gm.)  of  sodium  salicylate  for 
each  pound  of  weight;  but  in  rebellious  cases  advocates  massive  doses 
even  as  much  as  200  to  300  grains  per  diem.  In  place  of  salicylate  of 
sodium,  aspirin  and  benzosalin  may  be  used.  While  sodium  salicy- 
late cannot  prevent  sympathetic  uveitis,  its  use  during  traumatic 
iridocyclitis  seems  to  render  the  sympathetic  affection  less  virulent 


368  DISEASES  OF  CILIAHY  BODY  AND  SYMPATHETIC  INFLAMMATION 

than  otherwise  would  be  the  ease,  and  in  this  respeet  is  the  superior  of 
mercury.  Gifford  has  found  atoxyl  to  be  useful,  and  recently  has 
advised  larjie  doses  of  atophan,  40  to  fiO  grains  (2.6-3.9  ^ni.)  a  day 
especially  when  the  salicylates  are  not  well  born.  The  administration 
of  salvarsan  and  neosalvarsan  or  their  equivalents  have  been  tried  and 
favorable  results  have  been  reported;  indeetl  the  good  results  in  some 
of  the  cases  furnished  by  the  past  war  were  attributed  to  these  remedies 
(Morax).  The  author  has  seen  one  encourufziinj;  improvement  from  sal- 
varsan treatment.  licrnheimer  reports  good  icsults  in  one  case  from  the 
injection  of  tuberculin.  Intra-ocular  injections  of  bichlorid  of  mercury, 
in  the  opinion  of  the  author,  should  not  be  emploj-ed,  although  they 
have  been  highly  endorsed.  Subconjunctival  injections  have  been 
recommended.  The  author's  exjierience  with  them  in  this  tlisease  has 
not  been  encouraging,  (i.  S.  Derby  and  H.  X.  Piatt  conclude,  from 
their  own  experience  and  that  of  Zur  Xedden,  that  the  blood-serum  of 
an  individual  with  sympathetic  ophthalmia  may  be  of  curative  value 
when  injected  into  another  jiatient  with  the  same  disease.  Not  less 
than  1  ounce  (30  c.c.)  of  the  serum  was  u.sed.  Naturally,  the  possible 
influence  of  focal  infections  on  symj^athetic  ophthalmia  has  not 
escaped  attention  and  E.  V.  L.  Brown  has  reported  improvement  in 
the  disease  after  removal  of  infected  tonsils.  A.  Knapp,  discussing 
the  autotoxic  factor  in  sympathetic  oj^hthalmia  has  recorded  cases 
not  yielding  to  ordinary  remedies,  but  heljx'd  when  a  marked  int(>stinal 
sepsis  was  eliminated.  As  deficient  thyroid  secretion  is  believed  to 
lower  the  resistance  of  tissue  to  infective  processes  (Dunn)  thjToid 
extract  has  l)een  suggested — a  remedy  which  the  author  tried  in  one 
case  with  advantageous  effects,  which,  however,  were  only  temporary. 
Van  Lint  and  Coppez  have  adopted  the  methoti  known  as  the 
formation  of  a  fixation  abscess  in  the  treatment  of  intractai)le  irido- 
choroiditis  and  sj'^mpathetic  ophthalmitis.  One  c.c.  of  pure  oil  of  tur- 
pentine is  injected  in  the  subcutaneous  tissue  of  the  flank.  Usually 
in  a  few  days  an  abscess  fillod  with  aseptic  pus  develops.  About  the 
seventh  day  the  abscess  is  incised  and  the  contents  evacuated.  Al- 
though the  authors  state  that  the  procedure  does  not  produce  a  cuif, 
it  had  in  every  instance  led  to  an  arrest  of  the  progress  of  the  malady. 
As  the  result  of  treatment  the  affected  eye  may  recover  with  useful 
sight,  or  pass  into  atroj)liy  or  phthisis  bulbi,  or  grow  rpiiet,  with  the  for- 
mation of  complete  annular  adhesions  of  the  iris  to  the  cai)sul('  of  the 
lens,  which  has  become  cataractous. 

To  improve  vision  under  the  last-named  (•()n(liti()n,  iridectomy  and 
iridotomy  have  be(>n  tried,  but  tiie  results  ai"e  usually  unfav(trabl(>. 
Jvxtraction  of  the  cataractous  lens,  with  iridectomy,  also  i)resents  seri- 
ous difficulties.  For  those  cases  in  which  a  transformation  of  the  iris, 
lens  and  capsule  into  a  tough,  opactue.  and  inelastic  tissue  has  oc- 
cm-red,  Mr.  (ieorge  Critchett  ])racti.s(>d  the  following  operation:  The 
])atient  is  jjlaced  under  the  influence  of  an  an(\sthetic.  a  sjieculum  is 
introduced,  the  globe  is  fixed,  and  a  fine  cutting  needle  is  introduced 
through  the  cornea,  its  point  being  directed  to  the  center  ol  the  cjip- 


t 


SYMPATHETIC    INFLAMMATION  369 

sule.  This  structure  is  penetrated  by  making  a  rapid  rotary  move- 
ment, on  the  principle  of  a  gimlet.  A  second  needle  is  introduced  from 
the  opposite  side  and  the  points  separated  from  each  other,  the  result 
being  a  rent  in  the  center  of  the  capsule  and  the  escape  of  the  soft  lens 
matter.  The  operation  must  be  repeated  at  proper  intervals  until  a 
clear  pupil  has  been  obtained.  It  is  suited  to  young  eyes,  although  it 
may  succeed  in  adults,  as  in  one  case  in  the  author's  practice.  Care 
should  be  taken  to  avoid  wounding  the  iris.  With  this  operation  the 
author  has  achieved  gratifying  success. 

The  prognosis  of  sympathetic  ophthalmitis  while  it  is  essentially 
grave,  is  certainly  not  as  unfavorable  as  in  former  times,  probably 
owing  to  modern  antiseptic  procedures,  and  to  improved  methods  of 
treatment.  H.  Gifford  believes  that  "75  per  cent,  of  the  cases, 
if  seen  within  the  first  week,  retain  useful  sight  if  properly  treated." 
While  complete  and  permanent  recovery  occurs,  the  patient  can- 
not be  considered  cured  until  at  least  a  year  has  elapsed.  Eyes  in 
which  papillitis  is  the  manifestation  of  the  sympathetic  disease,  and 
which,  according  to  Schirmer,  never  begins  after  removal  of  the  exciting 
eye,  are  cured  by  enucleation  of  the  originally  injured  eye,  not  imme- 
diately, like  sympathetic  irritation,  but  in  the  course  of  several  weeks. 

Unless  the  disease  is  recognized  at  its  very  beginning  and  vig- 
orously and  properly  treated,  the  sight  of  the  eye  is  lost  and  the  organ 
shrinks.  Excepting  the  cases  of  pure  papillitis,  those  varieties  which 
appear  as  a  serous  uveitis,  and  which  retain  this  character  of  inflamma- 
tion, afford  the  most  satisfactory  prognosis.  It  is  extremely  important 
to  warn  patients  of  the  grave  nature  of  this  malady,  and  if  an  attempt 
is  made  to  save  an  eye  injured  in  the  manner  already  described,  it  must 
be  done  with  the  full  understanding  of  the  risks  which  are  under- 
taken, and  the  patient  must  be  kept  under  constant  observation. 

24 


CHAPTER  XI 
DISEASES  OF  THE  CHOROID 

Congenital  Anomalies. — Two  striking  congenital  anomalies 
occur  in  connection  with  the  choroid: 

1.  Coloboma  of  the  choroid  is  a  large  defect  in  the  choroid,  almost 
always  in  its  lower  part,  and  often  associated  with  a  similar  vice  of 
conformation  in  the  iris.  Other  ocular  abnormalities  which  may  be 
associated  with  coloboma  of  the  choroid  are  persistent  pupillary 
membrane,  curvature-defects  of  the  cornea,  strabismus,  nystagmus, 
microcornea  and  persistent  hyaloid  artery.  Coloboma  of  the  lids, 
harelip  and  dermoids  may  be  coincidcMit  anomalies.  In  the  association 
of  coloboma  of  the  choroid  and  iris  the  influence  of  heretlity  has  been 
emphasized  (Arlt,  de  Beck,  C.  E.  G.  Shannon). 

Examined  with  the  ophthalmoscope  the  deficient  area  appears  as  a 
glistening,  pearl-colored  patch,  often  irregular  on  its  surface,  owing  to 
the  development  of  several  protrusions  and  corresponding  intervening 
depressions,  and  bordered  by  an  irregular  pigment  line.  In  some  cases 
the  retina  may  be  recognized  as  a  translucent  veil  covering  the  defect, 
and  the  retinal  vessels  occasionally  pass  into  the  depression;  in  others 
the  retina  is  absent,  and  the  defect  will  be  represented  in  the  visual 
field  by  a  scotoma.  The  coloboma  may  include  the  optic-nerve  en- 
trance, either  partially  or  completely,  or  may  be  separated  from  it  by  a 
bridge  of  healthy  choroid.  It  may  be  confined  to  the  area  around  the 
disk,  or  pass  downward  as  far  as  it  can  be  followed,  and  be  associated 
with  a  similar  defect  in  the  iris,  from  which  it  is  separated  by  a  band  of 
choroid  tissue.  Sometimes  several  defects  are  present  in  the  same 
eye-ground.  Imperfect  closure  of  the  fetal  cleft  (choroidal  fissure)  is 
the  usual  explanation  of  this  condition.  Some  choroidal  defects 
resemVjling  coloboma  apparently  depend  ujwn  an  intra-uterine  choroi- 
ditis. According  to  E.  T.  Collins  and  W.  Lang,  all  colobomas  of  the 
choroid  may  be  explained  by  assuming  that  they  are  due  to  an  abnor- 
mal adhesion  of  the  retina  to  the  mesoblast,  which  may  take  place 
either  before  or  after  the  closure  of  the  fetal  cleft. 

In  addition  to  coloboma  in  the  usual  situations,  similar  defects 
have  been  described  in  the  macular  region  {nidodar  colohoina,  see  Fig. 
167)  and  the  nasal  half  of  I  lie  eye-ground  (B.  A.  Randall  and  the  au- 
thor), and  for  these  defects,  which  do  not  involve  the  optic  disk, 
Lindsay  Johnson  lias  proposed  the  name  cxtrafHipiUnry  coloboma. 
Atypical  cdlohonKi  of  tltc  choroid  may  also  be  situated  upward  and  t)Ut- 
ward  and  i)robably  in  any  part  of  the  clioroiil.  It  is  ilue  to  failur(>  in 
the  formation  of  dlood-ves.sels  in  the  inner  jiart  of  tlu'  nu'soblast  sur- 
rounding llie  secondary  optic  vessel  (Collins  and  Mavou). 
370 


HYPEREMIA   OF   THE    CHOROID 


371 


A  striking  developmental  abnormality  is  one  in  which  the  entire 
choroid  except  a  small  area  in  the  region  of  the  macula  is  absent.  To 
this  condition  the  name  choroideremia  has  been  given.  Both  eyes  are 
affected;  the  patients  are  night-blind  (Nettleship).  The  vision  may 
be  normal.  The  condition  has  been  well  studied  in  this  country  by 
A.  B.  Connor. 

2.  Albinism,  or  a  congenital  want  of  pigment  in  the  choroid  and  iris, 
is  a  deformity  met  with  both  in  a  complete  and  incom-plete  form.  It 
depends  upon  a  failure  of  pigment  in  mesoblastic  tissue  surrounding  the 
secondary  optic  vesicle  and  in  the  outer  layers  of  the  secondary  optic 
vessel  (Collins  and  Mayou). 


Fig.  159. — Congenital  defects  in  the  choroid;  one  large  coloboma  in  the  usual  situation 
with  two  smaller  areas  between  it  and  the  disk. 

The  iris  has  a  pink  or  pink  and  yellow  appearance,  due  to  the  reflec- 
tion of  light  from  its  own  blood-vessels  and  from  those  of  the  choroid, 
which,  in  the  most  pronounced  forms  of  the  defect,  can  be  seen  with  the 
ophthalmoscope  down  to  their  finer  branches.  The  anomal}^  is  most 
marked  in  early  childhood,  is  almost  invariably  associated  with  lack  of 
pigmentation  in  the  hair,  and  is  accompanied  by  nystagmus,  am- 
blyopia, and  high  grades  of  refractive  defects.  Usually  these  eyes  are 
photophobic.  In  many  instances  albinism  has  been  observed  in 
several  members  of  the  same  family,  and  seems  to  be  hereditary.  Semi- 
albinism,  especially  in  the  periphery  of  the  fundus,  is  sometimes  ob- 
served in  infants  and  may  persist  in  adult  life. 

Hyperemia  of  the  Choroid. — An  actual  hyperemia  could  be 
demonstrated  only  by  finding  a  real  distention  of  the  vessels  of  the  cho- 


372  DISEASES    OF   THE    CHOROID 

roid,  which  usually  arc  invisible,  and  the  congestion  of  the  choroid ,  de- 
scribcd  with  myopic  or  asthcnopic  eyes,  and  as  the  result  of  exposure 
to  brifiht  light  and  heat,  is  more  often  a  figure  of  speech  than  a  proved 
pathologic  condition. 

In  eyes  subjected  to  prolonged  strain,  the  result  of  uncorrected  ame- 
tropia, certain  changes  in  the  normal  appearance  of  the  fundus  arise 
which  are  usually  described  under  the  vague  term  "choroidal  distur- 
bance." We  may,  perhaps,  assume  hyperemia  where  the  nerve-head 
presents  distinct  redness,  which  is  imperfectly  differentiated  from  the 
unduly  flannel-red  appearance  of  the  surrounding  choroid,  or  where  the 
choroid,  instead  of  exhibiting  its  usual  uniform  red  color,  has  changed 
into  what  has  V)een  denominated  a  "woolly  choroid,"  with  faint  <lark 
areas  in  the  periphery,  indicating  the  interspaces  between  the  choroidal 
vessels,  and  more  orless  pronounced  retinal  striation  surrounds  the  disk. 
This  is  a  familiar  picture  in  many  cases  of  "eye-strain,"  and  where  the 
ophthalmoscope  reveals,  in  addition  to  the  other  signs  alread}-  de- 
scribed, an  appearance  as  if  fine  pigmented  grains  had  been  scattered 
over  the  fundus,  especially  its  central  regions,  the  nanie  "miliary 
choroidoretinitis  "  has  been  applied  to  it  by  Theobald.  Similar  lesions 
may  follow  exposure  to  great  heat  and  light,  and  may  be  seen  in  the 
eyes  of  puddlcrs,  etc. 

Treatment. — In  this  condition,  often  associated  with  the  subjective 
symptoms  of  aching  eyes,  some  intolerance  of  artihcial  light  and  dis- 
tinct asthenopia,  the  eye  should  be  atropinized,  dark  glasses  should  be 
worn,  and  after  the  irritable  condition  of  the  fundus  has  sufficiently 
subsided  a  proper  correction  of  the  refractive  error  should  be  ordered. 
Internally,  small  doses  of  iodid  and  of  bromid  of  potassium  serve  a 
useful  i)urpose. 

Choroiditis. — Under  the  general  term  choroiditis  are  included 
various  types  of  inflammation  of  the  choroid. 

Causes. — Choroiditis,  like  iritis,  may  depend  upon  (•onstitutional 
disorders,  infections,  toxins,  and  traumatisms,  or  upon  dis(>ase  in  other 
portions  of  the  eye.  Choroiditis  is  often  dassifieil  accortling  to  the 
probable  etiology — for  example,  syphilitic,  tubercidous,  traumatic,  etc.. 
choroiditis.      (Compare  with  pages  320,  327). 

Symptoms. — Certain  symptoms,  for  the  most  i)art  revealed  only  Ity 
the  ophthalmoscope,  are  present : 

1.  Alteration  in  the  uniform  dull-ri'il  siuface  of  the  eye-ground 
caused  by  (a)  the  absorption  of  the  pigment  epithelium;  (6)  patches  of 
pale-yellow  color  with  ill-defined  boundaries  due  to  exudation  [nrcttt 
choroiditis);  (c)  patches  of  white  color  due  to  exi)osure  of  the  underlying 
sclera  {atrophic  choroiditis);  and  {d)  patches  of  black  pigment,  vari- 
ously shaped,  scattered  over  the  fundus,  and  usually  bounding  the 
spots  of  atrophy  (piynu-nt  hvapimj). 

2.  Absence  of  external  manifestations  indicative  of  the  deep-seated 
disease,  except  where  acute  ;nid  puiulent  foliiis,  with  (he  liiseased 
process  noi  locMJi/ed  in  the  choidiil,  ;ire  aceoniiJaiucd  l>y  injection, 
cliemosis  ot  tlie  conjunct i\a,  etc. 


CHOROIDITIS  373 

3.  Changes  in  the  transparent  media  (lens,  vitreous)  b^-  the  forma- 
tion of  opacities,  as  a  secondary  result  of  the  choroidal  disease. 
Suhjectire  symptoms  peculiar  to  choroiditis  do  not  exist. 
Pain  usuall}^  is  not  present  except  in  purulent  forms,  and  in  such 
varieties  as  may  be  complicated  with  iritis  or,  as  the  result  of  associated 
refractive  error. 

Disturbance  of  vision  is  in  direct  relation  to  the  situation  of  the 
lesions  and  the  amount  of  atrophy.  If  the  choroidal  disease  is  periph- 
eral visual  acuteness  may  be  unaffected;  if  atrophic  patches  occupy  the 
macular  region,  central  sight  may  be  greatly  diminished  or  practically^ 
obliterated.  It  is  remarkable,  however,  that  even  in  extensive  diffuse 
choroiditis  good  vision  may  be  still  present.  If  the  disease  has  caused 
secondary  changes  in  the  vitreous  or  lens,  these  add  to  the  depreciation 
of  visual  acuteness. 

Scotomas,  both  positive  and  negative,  may  be  present.  Contrac- 
tion of  the  field  of  vision  in  certain  types  of  choroiditis,  and  especially  if 
secondary  atrophy  of  the  optic  nerve  has  occurred.  The  displacement 
of  the  retinal  elements  overlying  the  diseased  choroidal  areas  causes 
metamorphopsia;  sometimes  objects  appear  smaller  than  they  really  are, 
micropsia;  sometimes  larger,  macropsia.  In  the  early  stages  of  cho- 
roiditis the  patients  are  much  annoyed  by  subjective  symptoms  of 
light — i.  e.,  photopsies. 

Diagnosis. — This  is  readily  made  by  observing  with  the  ophthal- 
moscope the  appearances  briefly  summarized  in  paragraph  1  of  the  gen- 
eral symptoms. 

Inasmuch  as  choroiditis,  in  the  large  majority  of  cases,  is  compli- 
cated with  retinitis,  it  is  difficult  to  decide  whether  the  pigment  lies  in 
the  choroid  or  retina.  If  the  pigment  mass  is  covered  by  a  retinal  ves- 
sel, and  at  the  same  time  is  situated  in  a  deeper  layer  than  this,  its  posi- 
tion is  judged  to  be  in  the  choroid;  if  the  retinal  vessel  is  covered  by  the 
pigment  mass,  and  the  latter  is  situated  more  anteriorly,  its  position  is 
assumed  to  be  in  the  inner  surface  of  the  retina,  to  which  spot  it  has 
wandered  through  secondary  involvement  of  the  retina.  Pigment 
characterized  by  a  "lace-like  pattern,"  or  resembling  bone-corpuscles, 
is  always  in  the  retina  (Nettleship).  A  commingling  of  these  positions 
in  the  same  eye-ground  is  common. 

Course,  Complications,  and  Prognosis. — A  choroiditis  may  be  sud- 
den in  onset  and  pursue  an  acute  course;  for  example,  an  acute  choroidi- 
tis at  the  posterior  pole  of  the  eye  resulting  in  a  permanent  myopia 
(see  also  page  135)  or  purulent  forms  of  the  disease. 

More  commonh'  the  course  of  choroiditis  is  slow  and  chronic.  Be- 
ginning with  exudation  or  hemorrhage,  it  passes  by  slow  stages  through 
the  period  of  absorption,  atrophj^,  and  pigment  accumulation.  It  is  by 
the  last  signs  that  a  former  choroiditis  is  recognized,  and  the  changes 
are  called  "old  choroiditis"  or  "choroidoretinitis." 

The  following  structures  are  liable  to  become  involved  during  the 
course  of  a  choroiditis:  The  retina,  which  from  its  intimate  association 
with  the  choroid  through  the  pigment  epithelium  probably  does  not  es- 


374  DISEASES    OF   THE    CHOROID 

cape  in  any  instance,  and  in  many  the  association  of  disease  is  so  close 
that  we  apply  the  term  choroidoretinitis  or  retinochoroiditis;  the  optic 
nerve  (choroiditic  atrophy) ;  the  vitreous  (vitreous  opacities) ;  the  crystal- 
line lens  (posterior  polar  cataract) ;  the  iris  (iridochoroiditis) ;  and  the 
sclera  (scleroticochoroiditis) . 

The  prognosis  in. choroiditis  is  always  grave,  and  although  careful 
treatment  may  preserve  sight,  in  many  instances  great  depreciation  of 
vision  and  even  blindness  may  ensue.  Necessarily  the  prognosis  as  to 
vision  depends  upon  the  position  of  the  disease  and  its  relation  to  the 
macula. 

Pathologic  Anatomy. — In  non-purulent  forms  of  choroiditis  collec- 
tions of  round  cells  are  gathered  in  the  choroid,  especially  along  the 
vessels  between  this  membrane  and  the  retina,  and  hemorrhagic 
extravasations  may  be  seen.  Organization  of  this  round  -cell  exudation 
causes  atrophy  of  corresponding  portions  of  both  choroid  and  retina, 
union  of  the  two  membranes,  disappearance  of  the  pigment  layer  of 
the  retina  except  at  the  edges  of  the  lesions,  where  it  is  proliferated, 
and  wandering  of  the  pigment  cells  into  the  retina  along  the  lines  of  the 
vessels.  In  purulent  choroiditis  there  is  a  dense  cellular  infiltration 
of  the  choroid,  rapid  involvement  of  retina  and  vitreous,  panophthal- 
mitis, and  subsequent  phthisis  bulbi. 

As  alread}'  stated,  choroiditis  maj''  be  acute  or  chronic,  and  at  one 
time  was  classified,  according  to  the  pathologic  conditions,  into  plastic, 
serous,  and  purulent  forms. 

For  the  present  purpose  choroiditis  may  be  divided  into  superficial 
and  deep  choroiditis,  and  a  well-recognized  classification  may  be 
adopted  which  places  all  forms  under  one  of  two  heads:  (1)  Xon-sup- 
puraiive  exudative  choroiditis  and  (2)  suppurative  choroiditis  and 
iridochoroiditis. 

Treatment. — This,  in  general  terms,  demands  perfect  rest  for  the 
affected  e^'e,  protection  from  glaring  light,  and  the  administration  of 
remedies  indicated  by  the  cause  of  the  choroiditis.  Further  details 
will  be  reserved  for  the  sections  devoted  to  the  several  varieties  of 
choroiditis. 

Superficial  Choroiditis  (Epithelial  Choroiditis). — Instead  of  tiie 
general  dull-red  appearance  of  the  eye-ground,  the  larger  vessels  may 
be  manifest  as  rather  broad,  reddish,  or  j'ellowish-red  stripes,  which 
traverse  the  fundus  in  an  interlacing  manner,  and  between  which  are 
the  dark  intervascular  s])acos,  many  of  them  having  a  l()zeMg(>-shai)ed 
appearance.  This  is  due  to  the  absorjjtion  of  the  jjigiiiciit  (•i)ithelium 
and  the  capillary  layer  which  lies  just  beneath  it. 

In  certain  instances  it  is  physiologic,  and  is  commonly  seen  in  the 
peri])herv  of  eye-grounds,  often  by  jjicfcrcnce  occupying  a  s])mc('  down 
and  in  from  the  disk. 

It  may  be  universal,  the  onl}'  i)()rtion  of  the  eye-ground  escaping 
being  the  region  directly  confined  to  the  macula,  and  it  then  presents 
a  striking  picture  to  the  ophthalmoscojx".  The  larger  ve.s.sels  of  the 
clioroid-slroin.'i  pass  in  a  sinuous  inunnei'  .across  (he  eye-ground,  bring- 


i 


DEEP    CHOROIDITIS 


375 


ing  out  into  distinct  relief  the  pigmented  connective-tissue  cells  of  the 
choroid  proper  which  he  between  them  (consult  Fig.  168,  page  384). 


udations. 

The  atrophy  is  superficial  and  of  itself  does  not  disturb  vision.  Such 
appearances  are  seen  in  myopia;  in  "stretching eyes,"  where  hyperopic 
refraction  is  diminishing  or 
passing  into  myopic  refrac- 
tion; in  glaucoma;  and  some- 
times are  associated  with 
retinal  disease — for  example, 
pigmentary  degeneration. 

Deep  Choroiditis. — 1. 
Diffuse  Exudative  Choroiditis. 
— This  occurs  in  an  acute  and 
in  a  chronic  form — i.  e.,  the 
chronic  form  represents  the 
ophthalmoscopic  appearances 
commonly  observed  after  sub- 
sidence of  the  acute  process. 

In  the  earh^  stages  of  acute 
or  recent  choroiditis  the  dis- 
eased areas  are  represented  by 
yellowish-white,  sometimes 
greenish-graj^,   exudations, 

which  may  be  diffuse,  circumscribed,  or  dissem'nated,  and  which  shade 
gradually  into  the  surrounding  ej'e-ground,  or  which  ma}^  be  fringed 
with  pigment,  small  eroded  areas,  and  hemorrhages. 


Fig.   161. 


Diffuse  exudative  choroiditis  with 
choroidoretinitis. 


376 


DISEASES    OF    THE    CHOROID 


Later  these  areas  of  exudation  unclergo  absorption  anel  meta- 
morphosis, and  some  of  tlie  followiiifi;  conditions  are  present,  which 
may  be  named  chronic  choruiditia:  Instead  of  the  normal  red  of  the 
eye-ground  the  ophthalmoscope  reveals  white  or  yellowish-white 
plaques,  sometimes  separated  by  partly  normal  choroid,  more  often 
runiiinji  into  one  another  until  a  huf^e  expanse  of  exposed  sclera  is 
visible  throufihout  the  fundus. 

The  white  patches  appear  speckled  because  numerous  pigment 
masses  of  black  color  are  collected  upon  them,  irregular  in  form,  some- 
times gathered  in  lumps,  sometimes  assuming  variously  shaped  groups. 
They  lie  beneath  the  retinal  vessels  for  the  most  part,  although  usually 
pigment  will  be  found  collected  upon  these  retinal  vessels  showing  the 
participation  of  the  retina  in  the  process  {choroidoretinitis.  Fig.  161). 
In  other  patches  the  atrophy  has  not  been  sufficient  to  expose  the 
glistening  white  sclera,  and  there  will  be  found  the  lesions  of  super- 
ficial choroiditis,  namely,  band-like,  orange-yellow,  or  light  red  vessels, 
fi-eely  anastomosing  with  each  other,  and,  between  them,  the  pigmented 
epithelium.  In  still  other  spots  yellowish  exudations  are  evident, 
which  represent  the  earlier  stages  of  the  j^rocess  already  desci-ibed.     In 

these  circumstances  all  the  stages 
from  yellowish  extravasation  to 
complete  atrophy  are  visible. 

2.  Disseminated  Choroid- 
itis.— Another  foiin  which  may 
be  looked  ujjon.  accortling  to  a 
classification  adopted  by  some 
authors,  as  the  circumscribed 
variety  of  the  tyjie  just  de- 
scribed, is  that  which  is  known 
as  disseminated  choroiditis. 

In  this  type,  usually  l>e- 
ginning  in  the  periphery,  but 
gradually  approaching  the  cen- 
ter of  the  eye-ground,  numer- 
ous round  or  oval  spots  sur- 
rounded by  black  margins  are 
white  center  of  the  spot  is  the  exposed  sclera;  the  black 
altered  pigment.  Instead  of  a  white  center  there  may 
be  a  single  black  mass,  in  its  turn  encircled  by  a  yellowisii  ring. 
Where  the  spots  assume  a  punched-ttut  look,  as  if  a  siuui)  instrument 
had  cut  out  the  tissue  down  to  the  scleia,  the  mai'gins  of  the  incision 
being  l)or(lered  with  |)igment,  the  appearances  are  characteristii'. 

These  spots  of  disseminated  choioiditis  vary  greatly  in  iuiml>er. 
There  tnay  be  only  one  or  two,  or  the  eye-ground  may  be  (U)tted  over 
with  tliein.  lie!  ween  the  spots  the  choroidal  tissue  is  comparatively 
health\'.  'i'he  earlier  stages  of  such  spots  consist  in  small,  yellowish 
or  greenish-gray  exudations,  which  gradually  altsoili,  leaving  tlu' 
atrophic  inai'ks  which  lia\c  just   been  desciilied  ( I''ii:;.   1()2). 


Fi.;.  \( 
foil  11(1. 

margin. 


I)isseiiiiii;itc'(l  chorfjiditis. 


the 


CIRCUMSCRIBED    PLASTIC    CHOROIDITIS 


377 


Vitreous  opacities  are  often  present,  either  faint  and  floating,  or 
large,  string-like  and  membranous.  There  may  also  be  cataract  at  the 
posterior  pole  ot  the  lens. 

The  optic  nerve  may  become  affected  in  the  later  stages  of  deep 
choroiditis  and  undergo  a  species  of  atrophy  to  which  the  name 
choroiditic  atrophy  has  been  applied.  The  edges  of  the  disk  are  slightly 
hazy,  the  color  a  reddish  yellow,  and  there  is  contraction  of  the  retinal 
vessels.  Disseminated  and  other  forms  of  choroiditis  are  often  asso- 
ciated with  secondary  pigmentation  of  the  retina,  and  the  pigment 
patches  not  uncommonly  resemble  those  seen  in  pigmentary  degenera- 
tion of  the  retina.  These  pigmentations  are  especially  noteworthy  in 
forms  of  disseminated  choroiditis  due  to  syphilis.     One  form  of  dis- 


FiG.  163. — Disseminated  choroiditis  and  optic  neuritis  with  retinal  hemorrhages 
in  a  syphilitic  patient  in  the  Orthopedic  Hospital.  The  choroiditis  is  of  long  standing, 
the  neuroretinal  lesions  a  fresh  implantation. 

seminated  choroiditis  with  neuritis  and  peripapillary  retinal  opacity 
may  be  associated  with  a  focus  of  tuberculosis  in  the  optic  nerve 
(Gilbert,  Michel). 

3.  Circumscribed  Plastic  Choroiditis  (Jjocalized  Exudative  Chor- 
oiditis; Choroiditis  u'ith  Descemetitis). — Areas  of  choroiditis  are  not 
infrequently  encountered  in  young  persons  and  young  adults — that 
is,  from  fifteen  to  thirty  years  of  age — which  ophthalmoscopically 
do  not  differ  materially  from  those  types  already  described,  except 
in  their  circumscribed  character.  Usually  there  is  a  large,  bluish- 
white  patch  of  effusion,  generally  denser  in  its  center  and  thinning  off 
at  its  margin  into  the  healthy  fundus.     The  diseased  area  maj'  be 


378  DISEASES    OF   THE    CHOROID 

close  to  the  disk  (Hill  Griffith),  near  or  at  the  macula,  or  in  the  per- 
iphery (Friedenwald),  even  in  the  far  p('rij)lu'ry.  The  early  exudative 
stage  is  followed  by  erosion  and  atrophy,  but  the  course  is  compara- 
tively benign,  and,  unless  the  macular  region  is  involved,  there  is  no 
distinct  depreciation  of  central  vision.  Not  uncommonly  keratitis 
punctata  (desccmetitis)  and  vitreous  opacities  accompany  the  condi- 
tion (see  also  page  351).  Not  infrequently  rise  of  intra-ocular  tension 
may  be  present  and  an  attack  of  acute  glaucoma  may  be  precipitated, 
especially  if  a  mydriatic  is  employed.  Relapses  may  occur  in  the 
sense  of  reappearance  of  the  lesion  closely  adjacent  to  the  patch  of 
atrophy  remaining  after  the  subsidence  of  the  acquired  lesion.  Plastic 
choroiditis  near  the  disk  may  give  rise  to  an  appearance  similar  to 
that  of  optic  neuritis. 

lietinochoroidiiis  juxtapapillaris,  first  described  by  Jensen  as  a 
clinical  entity,  is  characterized  by  a  prominent  infiltration  close  beside 
the  nerve  head,  approximateh'  the  size  of  the  papilla  (sometimes  larger) 
and  usually  oval  in  shape,  which  wholly  or  partially  obscures  the 
retinal  vessels.  The  choroid  is  involved ;  opacities  form  in  the  vitreous. 
The  defect  is  interpreted  in  the  field  of  vision  by  a  scotoma,  sector- 
like, in  that  it  extends  from  the  blind-spot  to  the  periphery.  Jensen 
describes  the  fundus  oculi  as  otherwise  normal,  but  pigmentary  changes 
have  been  reported  in  the  opposite  eye  (Groes-Petersen)  and  in  the 
macula  in  the  corresponding  eye  (Van  der  Hoeve).  Precipitates  on  the 
back  of  the  cornea  have  been  reported.  The  disease  slowly  sub- 
sides and  leaves  an  area  of  atroph3\  Recurrences  may  take  place. 
Jensen  found  no  certain  etiologic  factor.  The  author  noted  persistent 
anemia  in  one  case.  Verhoeff,  who  examined  an  eyeball  of  a  syphili- 
tic patient  and  found  a  granulomatous  lesion  centered  near  the  disk 
margin  involving  the  inner  lay(M-s  of  the  retina  and  secondarily  the 
choroid  and  disk,  suggests  that  Jensen's  retinochoroiditis  may  some- 
times be  specific  in  origin.  This  certainly  is  not  the  cause  in  the 
majority  of  cases.     The  disease  occurs  in  young  persons. 

4.  Anterior  Choroiditis. — -To  this  condition  reference  has  been 
made  in  the  description  of  parenchymatous  k(Matitis  (see  page  290). 
The  lesions  are  situated  far  in  the  periphery,  and  may  exist  as  a  special 
form  of  disease,  or  result  from  an  extension  backward  of  affections  of 
the  iris  and  ciliarj'  body. 

Causes. — The  cause  of  deep  choroiditis,  eitlu>r  ditUise  or  dissemi- 
nated, is  ac(iuired  syphilis  in  a  number  of  cases,  and  the  ilisea.se 
appears  from  six  months  to  two  years  after  the  initial  infection.  Some- 
times it  is  postponed  to  a  much  later  period  (tertiary  period).  Opaci- 
ties in  the  vitreous  are  coniiimn  in  syphilitic  choroiditis.  Although 
certain  choroidal  lesions  have  been  looked  upon  as  t>sp(>cially  charac- 
teristics of  syphilis,  it  is  not  saie  to  atti'Uipt  to  make  a  tliagnosis  of 
syphilis  simply  by  the  appearances  of  any  of  the  varieties  of  choroiditis 
(compare  with  syphilitic  cliotioretinitis,  page  4()7).  Diffuse  syphilitic 
choroiditis  depends  upon  a  lilt lal ion  of  tiie  toxin  of  syphilis,  or  ptMhaps 
a  dissemination  of  its  acti\e  agent    (Spirocjia'ia   pallida)   througiiout 


ANTERIOR   CHOROIDITIS  379 

the  tissue  of  the  choroid.  If  the  deposit  of  the  toxin  remains  locahzed 
the  circumscribed  varieties  of  the  affection  arise.  Disseminated 
choroiditis,  choroidoretinitis,  and  secondary'  pigment  degeneration  of 
the  retina  are  seen  in  children  the  subjects  of  hereditary  syphiKs.  Cho- 
roiditis due  to  acquired  syphihs  usualh'  affects  both  eyes.  The 
Wassermann  test  should  be  applied  to  all  cases  of  choroiditis.  Igers- 
heimer  maintains  that  typical  disseminated  choroiditis  (page  376) 
is  less  commonl}'  caused  b}^  sj^philis  than  is  usually  supposed  to  be 
the  case.  Alexander  is  also  of  this  opinion  save  only  if  the  disease 
is  in  association  with  vitreous  opacities.  To  the  diagnostic  import  of 
vitreous  opacities  Igersheimer  is  unwilling  to  attach  importance  in  ex- 
cluding typical  disseminated  choroiditis,  in  the  majority  of  the  cases, 
from  etiologic  relationship  with  sj^philis.  Igersheimer,  however,  does 
not  eliminate  s^^philis  as  a  causative  factor  in  many  forms  of  dissemi- 
nated choroiditis. 

A  disseminated  choroiditis  {hereditary  choroiditis)  affecting  both 
ej'es  is  occasionally  encountered  as  a  family  disease  independently  of 
syphilis  and  associated  with  disorders  of  the  central  nervous  system 
(Hutchinson),  and  familial  chorioretinitis  has  been  observed.  Patches 
of  choroiditis  are  found  in  the  eyes  of  children  born  with  cataract. 

A  choroiditis  quite  indistinguishable  from  the  forms  described  may 
result  from  any  injury  (traumatic  choroiditis).  As  the  result  of  con- 
cussion injuries  of  the  globe  pigmented  choroiditis  may  arise  in  the 
form  of  scattered  areas  of  variously  shaped  pigment  masses,  usually  of 
small  size,  sometimes  granular,  interspersed  with  small  erosions  and 
spots  of  atrophy. 

J\Iany  cases  of  choroiditis,  especially  of  the  disseminated  varietj',  as 
well  as  of  the  diffuse  and  localized  exudative  manifestations,  are  due 
to  tuberculosis  {tuberculous  choroiditis).  This  etiologic  factor  can  be 
demonstrated  by  tubercuUn  injections,  which  are  followed  bj^  local 
as  well  as  general  reaction. 

Choroiditis  has  also  been  ascribed  to  disturbances  of  nutrition, 
metabolic  disorders,  nephritis  {allmminuric  choroiditis),  diseases  of  the 
liver  {ophthalmia  hepatica),  anemia,  chlorosis,  acute  infectious  diseases, 
and  to  infections  arising  from  the  nasopharynx,  accessory  sinuses,  and 
the  teeth  (pyorrhoea  alveolaris).  In  acute  plastic  choroiditis  the  fol- 
lowing etiologic  factors  are  active:  focal  infections,  for  instance,  ton- 
sillitis, oral  sepsis,  intestinal  toxemia,  etc.,  auto-intoxication,  typhoid 
fever  and  other  infectious  fevers,  influenza  and  pneumonia.  Gradle 
suggests  that  the  infecting  material  from  the  accessory  sinus  or  other 
focus  of  infection  msiy  gain  access  to  this  region  through  the  posterior 
ciliary  vessels.     (Additional  causes,  see  page  350.) 

The  prognosis  is  always  grave  if  the  process  is  an  extended  one  and 
the  macula  involved;  it  is  best  in  the  sj^philitic  cases  and  in  some  forms  • 
of  acute  plastic  choroiditis,  in  which  the  results  of  treatment  are  most 
satisfactory.  The  vision  depends  largely  upon  the  position  of  the 
lesions ;  if  the  macula  escapes  it  may  be  c^uite  good  and  even  entirely 
normal. 


380  DISEASES    OF   THE    CHOROID 

Treatment. — This  depends  upon  the  cause.  If  it  is  syphilis,  inunc- 
tions of  mercurial  ointment  should  be  prescribed,  to  be  followed  by 
iodid  of  potassium,  or  the  mercury  may  be  given  by  the  mouth  in  the 
form  of  the  protiodid,  or  by  the  hypodermic  method.  Later,  a  pro- 
lonjred  course  of  bichlorid  of  mercury  combined  with  tincture  of  iron  is 
advisable.  S(ilr<irsaii  and  ncosalvarsan  or  their  ecpiivalent — arsphe- 
namin — in  the  later  states  of  choroiditis  have  not  seemed  to  the  author 
to  be  of  much  value;  in  acute  forms  their  action  is  more  satisfactory 
(compare  page  335).  Subconjunctival  injections  have  been  recom- 
mended. They  may  be  composed  of  bichlorid  of  mercury  ( 1 :  2000- 
4000),cyanid  of  mercury  (1:5000),  or  physiologic  salt  solution.  Pilo- 
carpin  sweats  may  be  tried,  and  in  non-syphilitic  cases  their  effect 
is  sometimes  strikingly  favorable;  in  old  cases  strychnin  and  the 
galvanic  current  have  been  advised.  If  tuberculosis  is  the  suspected 
or  definitely  established  cause,  tuberculin  should  be  administered  (see 
page  341).  Certain  cases  of  intra-ocular  tuberculosis  {choroiditis), 
especially  characterized  by  chronicity  of  the  lesions,  are  distinctly 
amenable  to  this  treatment.  All  clo.se  work  must  be  forbidden;  the 
eyes  should  be  protected  with  dark  glasses.  Should  a  mydriatic  be 
employed  in  the  treatment  of  acute  choroiditis,  its  effect  on  the  intra- 
ocular tension  must  be  carefully  watched  and  frequent  tonometric 
tests  are  advisable.  Dionin  is  of  service.  Naturally,  general  medi- 
cation should  be  governed  by  the  probable  etiologic  factors,  and  what 
has  been  written  on  page  351  applies  to  the  disease  now  under  discus- 
sion, and  in  acute  choroiditis,  especially  of  the  circumscrilied  variety, 
great  care  should  be  exercised  in  a  search  for  focal  infection,  particu- 
larly in  the  buccal  mucous  membrane. 

Central  choroiditis  is  the  name  applied  to  choroiditis  confined 
to  the  region  of  the  macula;  its  manifestations  are  numerous. 

There  may  be  an  irregular  patch  of  exudation,  semi-  or  compl(>tely 
atrophic,  and  bounded  by  pigment.  This  is  recognized  objectively  by 
the  ophthalmoscope,  and  subjectively  by  a  scotoma  in  the  field  of 
vision.  Occasionally  the  area  consists  of  an  epithelial  atrophy,  either 
with  a  well  maiked  l)order,  somewhat  irregular  in  outline,  or  with  a 
border  less  sharply  marked,  and  with  pigment  distributed  over  the 
surface  of  the  defect.  Sometimes  the  lesions  consist  of  areas  of  yellow- 
ish exu<lalion,  interspersed  with  small  rouml  and  lint>ar  j)igment 
masses  and  dot-like  hemorrhages.  Kipp  called  special  attcMition  to 
heinorrhcujic  niitnil  ntiitochoroiditis  in  non-myopic  eves,  characterized 
by  an  oval  or  lound  :irca,  surrounded  by  hmiorrhage. 

Again,  the  macula  may  be  occupied  or  surrounded  by  a  large  white 
patch,  the  rest  of  the  e.\'e-ground  being  normal.  Occasionally  tht^  area 
is  entirely  circular  .iimI  iIh'  ileep  vessels  exposed,  oi'  they  may  be 
atrophied  and  conNcricd  into  white  lines  (sclerosis  o(  the  choroidal 
vessels).  Pigment  is  usuall\'  absent.  To  these  types  of  choroidal 
change  the  name  senile  oreoUir  (ilrophii  of  the  ehoroi<l  is  usu;dly  applied. 
In  some  c;ises,  owing  to  atro|)hy  of  the  ))igmented  epithelium  anil 
tlic   <'liori(»capill;iris  tlu-re  is  widi-spreiid  e\|)osure  of  the  largi-r  vessels 


CENTRAL    CHOROIDITIS 


381 


of  the  choroid,  which,  white  streaked  and  sclerotic,  constitute  a  striking 
ophthahnoscopic  picture  {primary  sclerosis  of  the  choroid).  Seen  in 
elderly  people  it  may  be  regarded  as  a  senile  degeneration;  it  has  also 
been  attributed  to  syphilis  and  to  arteriosclerosis.  Extensive  sclerosis 
of  the  choroidal  vessels,  which  are  apparently  converted  into  white  lines, 
with  some  pigmentation  in  the  peripherj-  of  the  eye-ground,  but  with 
normal  disks  and  retinal  vessels,  has  been  reported  as  a  family  disease, 
that  is,  it  may  occur  in  several  members  of  the  same  family.  A  form  of 
choroiditis  especially  described  by  Forster  is  known  as  choroiditis 
areolaris,  and  affects  the  region  of  the  disk  and  the  macula.  The  spots 
are  numerous,  but  larger  than  those  in  disseminated  choroiditis.  Their 
centers  may  be  white,  and  are  usually  black  rimmed  and  sometimes 
undermined.   A  peculiarity  of  this  type  of  choroiditis  is  that  the  foci, 


Fig.  164. — Central  atrophic  choroiditis;  on  the  temporal  side  of  the  disk  there  is  a 
semi-atrophic  area — the  so-called  conus  (from  a  patient  in  the  Philadelphia  General 
Hospital) . 


first  appearing  in  the  macular  region,  in  successive  stages  gradually 
approach  the  periphery  where  the  most  recent  lesions  will  be  found. 
Occasionally  the  macula  is  covered  with  a  greenish  or  grayish  plastic 
exudate,  of  various  shapes,  often  surrounded  by  a  rim  of  hemorrhage 
and  later  by  a  zone  of  erosion  or  atrophy — probablj'  a  late  stage  of 
plastic  choroiditis  (see  page  377). 

In  the  same  region  there  is  observed  another  variety  of  the  disease, 
first  described  by  Tay  and  Hutchinson  as  central  senile  guttate  choroid- 
itis, marked  by  the  appearance  of  numerous  white,  glistening  dots, 
somewhat  resembling  the  earlier  stages  of  albuminuric  retinitis  (Nettle- 
ship)  and  always  symmetric,  though  sometimes  an  interval  of  time 
elapses  before  the  implication  of  the  second  eye.     The  white  spots  are, 


382 


DISEASES    OF   THE    CHOROID 


due  to  colloid  degeneration  and  calcareous  formations  in  the  choroid 

and  are  associated  with  secondary  involvement  of  the  retina.  Oc- 
casionally the  macular  region  contains  an  oval  or  circular  patch  of 
dense  grayish-white  or  yellowish-white  tissue,  which  lies  beneath  the 
retina  and  seems  to  be  in  the  choroid,  and  which,  according  to  Nettle- 
ship,  belongs  to  this  group  of  central  senile  choroidoretinitis.  Usually 
there  are  contraction  of  the  field  of  vision  and  negative  scotoma.  Large 
areas  of  colloid  change  may  also  occur  without  disturbance  of  vision 
{verrucosities  of  the  choroid),  Fig.  165;  also  disseminated  colloid  lesions. 

It  is  important,  if  possible,  to  recognize  all  forms  of  central  choroid- 
itis before  a  cataract  operation  is  performed.  They  may  be  sus- 
pected if  there  is  imperfect  central  fixation  for  light,  l)ut  really  can  be 
positively  determined  onh'  while  the  cataract  is  still  incipient  and  the 
ophthalmoscopic  examination  is  possible. 


Fig.   165. — Colloid  change  in  the  macular  region. 


Causes. — Central  choroiditis  of  inflaiiiniatory  type  nuiy  be  caused 
by  syphilis  and  also  l)y  blows  upon  the  eye.  Chronic  atrophic  choroid- 
itis in  this  region  is  seen  in  myopia,  and  Gould  has  ilescribetl  macular 
choroiditis  as  the  result  of  uncorrected  ametropia  and  insufficiency  of 
the  internal  recti  muscles,  even  in  non-stretching  eyes  (anutropic 
choroiditis).  Nettleship  l)elieves  that  central  senile  clioroidort'tinitis, 
in  its  various  manifestations,  depends  chiefly  upon  disea.'^e  of  the 
posterior  ciliary  arteries,  eitlier  the  trunks  themselves  or  the  branches 
which  perforate  the  sclera  near  the  optic  nerve,  and  that  any  affec- 
tion of  the  retina  Itself  is  secondary. 

Treatment.  In  the  syphilitic  vari(»ty  the  usual  remeihes  are  inth- 
cated.  In  types  coimectecl  witli  refractive  error  the  best  possible  cor- 
rection should  be  given  and  al)solute  eye-rest  enjoined.  In  the  senile 
varieties,  both  the  ordinary  and  the  guttate  types,  treatment  appears 
to  have  no  influence. 


UNCLASSIFIED    FORMS    OF    CHOROIDITIS 


383 


Unclassified  Forms  of  Choroiditis. — Besides  the  diseases  of  the 
choroid  which  have  been  described  others  appear  which  cannot  be 
definitely  classified: 


.*<1??3 


'^^. 


> 


Fig.   166. — Central  cone-shaped  lesiuu  lu  oi.wioid,  surrounded  by  lines  of  edema  (patient 
in  the  University  Hospital). 


Fig.  167.— Mar-alar 


inpare  with  Fig.  164). 


Large  patches  of  atrophy  not  located  in  special  portions  of__the 
choroid,  resulting  probably  from  the  absorption  of  former  hemorrhages, 


384 


DISEASES    OF    THE    CHOROID 


or,  perhaps,  tul)oroulous  areas;  hemorrhagic  choroiditis  occurring,  as 
pointed  out  by  Hutchinson,  especially  in  young  men,  and  resulting  in 
numerous  spots  of  atrophy  which  are  not  readily  distinguished  from 
those  of  the  syphilitic  variety;  yellowish  or  t)ther  spots  of  choroidal 
disease,  which  have  been  attributed  to  the  action  of  intense  light  or  the 
glare  of  heat;  slight  macular  changes  in  the  form  of  small  yellowish 
or  maroon-colored  spots,  sometimes  with  a  few  scattered  pigment 
granules  in  the  immediate  vicinity  of  the  fovea,  which  do  not  affect 
vision  and  are  unnoted  by  the  patient.  These  have  been  attributeil 
by  some  authors  to  the  influence  of  abnormal  refraction,  but  are 
sometimes  seen  in  association  with  transient  albuminuria,  and  prob- 
ably represent  small  spots  of  degeneration  due  to  vascular  disease, 
perhaps  of  the  short  jiosterior  ciliary  arteries  which  suj^ply  the  region 
of  the  macula. 

Myopic  Choroiditis. — Atrophy  of  the  choroid,  commonly  of  a 
local  character,  occurs  in  severe  or,  as  it  has  sometimes  been  called, 
malignant  myopia,  and  is  observed  either  in  connection  with  or  sur- 
rounding the  nerve-head.     It  is  caused  by  the  elongation  which  occurs 

at  the  posterior  pole  of  the  eye, 
and  receives  the  name  posterior 
staphyloma;  if  the  disk  is  en- 
tirely surrounded  by  the  area 
of  atrophy  the  name  annular 
posterior  staphyloma  or  circum- 
pnpillary  atrophy  is  suitable 
(Fig.  lt)8). 

The  term  sclcroticochoroid- 
itis  posterior  is  also  applied 
to  this  variety  of  choroidal 
change,  just  as  anterior  sclerot- 
icochoroiditis  is  the  name  given 
to  the  inflammatory  affection 
which  attacks  circumscribed 
portions  of  the  anterior  part 
of  the  choroid,  with  corre- 
sponding portions  of  the 
sclera,  and  which,  in  aggra- 
vated instances,  may  give  rise 
to  staphylomatous  bulging  and 
giadu;d  loss  of  vision  from 
opacify  of  llie  vilreous  ;iii(l  cornea  (see  page  ol.')).      llirschberg  objects 


Fi«i.  16s. —  Myopic  choroiditi.s.  The  cut 
illustrates  posterior  staphyloma — the  white 
area  surrouiidiiiK  the  nerve:  atroiihiccljoroiditis 
in  the  macula — flie  white  patch  bordered  by 
piRmeiit  in  the  central  part;  and  general  ex- 
posure of  the  choroidal  vessels  by  ab.-orption  of 
the  retinal  pitrnicnl  epithelium. 


believes    the 


<ions    are 


to    llie    teiiii    "niNdpic    choroiditis,"    as    he 
mecliaiiical  ;ind  not  inll;iimn;ttory  in  origin. 

Senii-afraphic  and  atrophic  crescents  (often  in;iccuialely  c:illed 
"conns")  also  ai)pear  at  tlie  outer  margin  of  the  disk  in  asligniatic 
eyes,  and  in  eyes  undergoing  cli;inge  owing  to  the  distention  of  their 
coats  from  too  close  work  .-iggravatetl  liy  inii)errectly  or  improperly  cor- 
rccteti  errors  of  refraction.      In  hy|)er(.i)ic  .iiid  eiiiiiiet  ropic  eyes  n:u-row 


SUPPURATIVE    CHOROIDITIS   AND    IRIDOCHOROIDITIS         385 

white  crescents,  usually  at  the  temporal  side  of  the  disk,  are  often 
evident.     These  are  the  so-called  scleral  crescents. 

In  the  macular  region  in  myopia  there  may  be  very  decided  semi- 
atrophic  or  atrophic  patches  having  the  general  characteristics  of  the 
spots  already  described,  and  greatly  interfering  with  vision.  The  proc- 
ess begins  in  the  form  of  small  rents  which  gradually  coalesce  into  an 
atrophic  patch.  In  like  manner  this  area  may  be  involved  by  a  hemor- 
rhage in  progressive  myopia,  which  after  absorption  leaves  impaired 
vision,  owing  to  the  damage  of  the  overlying  retina.  The  vessels  of  the 
choroid  are  exposed  by  maceration  and  absorption  of  the  retinal  pig- 
ment epithehum,  causing  the  appearance  described  under  superficial 
choroiditis  (see  Fig.  168,  and  also  page  374). 

Suppurative  Choroiditis  and  Iridochoroiditis  (E7ulophthal- 
mitis  [Fuchs]). — Acute  iritis  occasionally  becomes  complicated  with 
inflammation  of  the  choroid  (see  page  331),  and  the  chronic  type  of 
iridochoroiditis,  which  tends  to  loss  of  vision  and  shrinking  of  the  eye- 
ball, have  been  described  (see  pages  342  and  352). 

The  present  disease,  however,  is  distinguished  by  a  suppurative 
process  which  may  begin  in  the  choroid,  or  in  the  vitreous,  or  in  the 
aqueous  chamber  and  pass  into  the  vitreous.  Fuchs  classifies  endoph- 
thalmitis thus:  the  purulent  exudation  remains  confined  to  the  posterior 
part  of  the  eye  {abscess  of  the  vitreous),  or  extends  from  the  posterior 
region  to  the  anterior  chamber,  or  begins  in  this  chamber  {purulent 
iritis)  or  the  whole  interior  of  the  eye  is  involved  {panophthalmitis). 

Symptoms. — If  there  is  sufficient  transparency  of  the  media,  and 
in  simple  abscess  of  the  vitreous  there  may  be  only  slight  or  no  exterior 
manifestations,  a  mass  of  exudation  may  be  seen  behind  the  lens  in  the 
vitreous,  giving  rise  to  a  yellowish  reflection  when  viewed  by  transmit- 
ted light,  or  often  visible  to  the  unaided  eye  {pseudoglioma,  "amauro- 
tic cat's  eye;"  see  also  page  451).  At  first  the  tension  may  be  raised 
and  the  anterior  chamber  is  shallow;  later  the  tension  is  lowered;  the 
pupil  is  dilated;  vision  is  lost,  although  light  perception  may  at  first 
be  present. 

If  the  process  remains  localized  in  the  vitreous  the  inflammatory 
symptoms  subside,  the  intra-ocular  tension  is  lowered,  membrane  for- 
mation takes  place  and  the  eyeball  gradually  shrinks  {atrophy  of  the 
eyeball).  If  the  process  passes  forward  into  the  aqueous  chamber  or 
begins  there,  there  are  suppurative  inflammation  of  the  iris,  haze  of 
the  cornea,  turbidity  of  the  aqueous,  and  exudation  in  the  pupil  area. 
Pain  increases  and  becomes  severe.  The  eyeball  may  ultimately 
shrink  or  the  inflammation  may  spread  to  all  of  the  interior  ocular 
coats  and  the  edema  of  the  lids  and  chemosis  of  the  conjunctiva  are 
intense,  the  pain  violent,  and  the  constitutional  symptoms — fever, 
chills,  nausea,  and  vomiting — are  very  marked.  The  inflammation 
involves  Tenon's  capsule  and  causes  protrusion  of  the  globe,  which 
is  pressed  against  the  swollen  lids  until  these  can  scarcely  be  sepa- 
rated on  account  of  the  swelling  and  edema.  Finally  rupture  of  the 
sclera  or  sloughing  of  the  cornea  occurs,  the  purulent  matter  finds 


386  DISEASES    OF   THE    CHOROID 

a  vent,  the  pain  subsides,  and  in  about  six  weeks  the  ball  is  soft,  sight- 
less, shrunken,  and  free  from  pain.  The  second  outcome  of  purulent 
choroiditis  is  known  as  panophthalmitis,  and  the  ultimate  result  is 
phthisis  bulbi. 

Causes. — Suppwative  choroiditis,  or  iridochoroiditis,  may  be  caused 
by  the  introduction  of  pathogenic  microbes  in  the  same  manner  as  in 
purulent  cyclitis — that  is,  the  infection  comes  from  the  outside.  It  is, 
in  short,  an  exogenous  infection.  In  these  circumstances  it  may  arise 
as  the  result  of  perforating  wounds  and  injuries,  operative  wounds 
which  have  become  infected — for  example,  cataract  extraction — 
sloughing  ulcers  and  abscesses  of  the  cornea,  and  prolapse  of  the  iris 
and  thinned  cj-stoid  corneal  cicatrices,  those,  for  instance,  which  are 
created  bj-  corneoscleral  trephining,  a  diminutive  aperture  having 
formed,  permitting  the  entrance  of  micro-organisms. 

Suppurative  choroiditis  may  also  be  caused  by  embolism  from  a 
focus  of  suppuration  {endogenous  infection) ,  and  produces  the  condition 
which  is  known  as  metastatic  ophthalmitis.  From  the  etiologic  stand- 
point, following  Axenfcld's  classification,  metastatic  ophthalmitis  may 
result  from  puerperal  pyemia,  which  is  its  most  frequent  cause;  from 
surgical  pyemia,  which  includes  all  cases  which  arise  from  injury, 
operations,  and  local  purulent  areas,  even  where  the  last-named  con- 
ditions are  non-traumatic,  but  have  an  internal  origin,  and  may  have 
their  situation  in  the  mucous  membrane  of  the  digestive,  pulmonary, 
and  urinary  organs  (Groenouw);  from  cryptogenetic  septicopyemia, 
that  is,  the  point  of  entrance  of  the  infection  has  not  definitely  been 
determined,  and,  finally,  from  infectious  diseases,  particularly  pneu- 
monia, influenza,  measles,  scarlet  fever,  diphtheria,  and  small-pox. 
The  disease  may  also  result  from  cerebrospinal  meningitis,  basic  menin- 
gitis, dysentery,  bronchitis,  whooping-cough,  inflanunation  of  the  um- 
bilical vein,  and  thrombosis  of  the  orbital  veins.  It  may  l)e  bilateral 
or  unilateral,  and  the  puerperal  cases  usually  ilev(>lop  iluring  the  first 
two  weeks  of  the  disease,  but  may  be  delayed  until  the  seventh  week. 
Ulcerative  endocarditis  is  a  frequent  complicating  factor. 

Pathology. — Examination  of  eyes  in  which  suppurative  choroiditis 
has  occurred  shows  tiie  presence  of  a  thick  purulent  infiltration  of  the 
choroid,  involvement  of  the  overlying  retina,  and  soinetinu's  conversion 
of  the  entire  vitreous  into  a  purulent  material.  In  the  metastatic  vari- 
ety of  the  affection  the  septic  masses  enter  into  the  capillaries  of  the  eye. 
Som(!times  the  retina  is  exclusively  or.  at  least,  first  affected,  later  the 
uveal  tract  is  also  involved. 

Fuchs' investigations  of  the  anatomic  changes  in  intlanunation  of 
the  clioroid  and  those  which  result  from  infection  of  the  vitreous  indi- 
cate that  the  inilamination  spreads  tn  the  inner  lining  of  the  vitreous, 
especially  to  the  p<trs  cili(tris  ntin.(r  and  to  tlie  retina  itself.  I'urulent 
retinitis  results,  and  the  choroitl  is  seriously  involved  where  the  intlani(>d 
retina  remains  in  contact  with  it  {endophthalmitis  st  ptica). 

Streptococci,  staphylococci,  and  sometimes  Frankel-Weichselbnum 
pneiiniococci  have  been  found.  an<l  in  many  cases  of  |)anophth;dniiti.< 


SUPPURATIVE    CHOROIDITIS   AND    IRIDOCHOROIDITIS 


387 


not  necessarily  metastatic  in  origin  special  bacilli  are  present,  some  of 
which  have  been  determined  to  have  pathogenic  significance.  This  is 
particularly  true  after  injuries  of  the  eye,  and  in  a  number  of  instances 
those  organisms  have  been  found  to  which  Haab  has  given  the  name 
panophthalmitis  bacilli,  and  which  belong  to  the  group  of  the  "hay 
bacilli." 

Prognosis. — This  is  most  unfavorable,  and  almost  invariably  a 
shrunken  eyeball  is  the  result  of  the  inflammation.  A  few  cases  of 
recovery  from  suppurative  iridochoroiditis  following  cerebrospinal  men- 
ingitis have  been  recorded.  The  termination  of  destructive  ophthal- 
mitis in  children  is  usually  not  fatal,  but  a  few  deaths  have  occurred, 
generally  from  meningitis  (see  also  page  452).  In  bilateral  cases  of 
puerperal  metastatic  ophthalmitis  the  mortality  is  exceedingly  high, 
only  a  few  authentic  cases  of  recovery  being  on  record. 


Fig.  169. — ^Leukosarcoma  of  choroid,  showing  at  (a)  constriction  which  marks  where 
choroidal  capsule  was  ruptured  and  where  retina  became  adherent,  being  pushed  forward 
with  growth' of  upper  part  of  tumor  (b),  which  assumes  a  mushroom  shape.  At  (c)  cho- 
roidal origin  of  growth  is  seen. 


Treatment. — Copious  irrigations  with  the  usual  antiseptic  lotions 
are  useful,  with  sufficient  morphin  to  relieve  pain,  and  locally,  fre- 
quently changed  ice  compresses.  In  later  stages  hot  fomentations  are 
sometimes  more  agreeable,  a  square  of  lint  soaked  in  heated  bichlorid 
solution  being  applied  to  the  eye;  and  internally,  opium  and  quinin  in 
full  doses  are  indicated.  If  there  is  much  pain  before  spontaneous 
rupture  has  occurred,  a  free  incision  into  the  sclera  will  bring  relief. 
The  methods  of  treatment  to  prevent  the  spread  of  septic  processes  after 
injury  have  been  described  on  page  32,  and  other  methods  of  treat- 
ment will  be  found  on  page  452. 

Surgeons  differ  in  regard  to  the  advisability  of  enucleating  the  globe 
during  the  acute  stages  of  panophthalmitis,  some  operators  declining  to 
perform  excision  in  such  circumstances,  in  the  belief  that  meningitis  is 
liable  to  follow,  while  others  do  not  recognize  this  danger. 

The  author  does  not  hesitate  to  enucleate  an  eyeball  m  which  there 
is  suppuration  if  the  surrounding  orbital  tissues  are  not  yet  involved  in 
the  process;  but  agrees  with  Pooley  that  where  the  process  has  reached 


388 


DISEASES    OF   THE    CHOROID 


a  great  height,  whore  there  is  purulent  infiltration  of  the  orbital  tis- 
sui^s,  and  where  the  affection  has  begun  posteriorly,  as  in  some  varieties 
of  septic  iridochoroiditis,  the  operation  of  enucleation  is  surrounded  by 
dangers.  In  a  certain  nunib3r  of  casss  it  has  been  followed  by  menin- 
gitis. Therefore  under  these'conditions  evisceration  is  preferred.  But 
even  after  evisceration  there  may  l)e  a  great  accumulation  of  inflamma- 
tory pro(hicts  behind  the  scleral  cup,  and  to  these  a  vent  nuist  i)e  given. 
Tumors  of  the  Choroid. — The  most  frequent  neoplasm  of  the 
uveal  tract  and,  for  the  present  purposes  of  description,  of  the  choroid 
is  sarcoma.  Most  commonly  it  appears  as  a  pigmented  growth  (mclano- 
sarcoma);  more  rarely  (1  in  8,  according  to  W.  C\  RocklifTe)  without 
pigment  (leukosarcoma) . 

Sarcoma  of  the  choroid,  accord- 
ing to  E.  Pawel,  is  most  frequent 
\  between  the  ages  of  fifty  and  sixty. 


Fkj.    170. —  Muiro.-.((ji)ic   appearance  of  I'm;.  171.      1,  ^i^;lllL■Iltl•(i  fiat  .sarcoma; 

a  pigmented  choroidal  sarcoma — flattened  2,  cyst  of  retina;  '3,  detacliinent  of  retina 

growth  or  so-called  cake-like  form.     One  in  portion  of  eye  opposite  to  position  of 

extrascleral  nodule.  -  tumor. 


A  good  many  cases,  however,  occur  at  an  earlier  period  than  this,  but 
the  disease  is  rare  under  the  twentieth  year.  Men  are  more  frequently 
affected  than  women,  and  tiie  left  eye.  accor(Uiig  to  some  statistics,  is 
more  •A\)\  to  be  involved  than  its  fellow. 

Pathology. Thr  growth  usually  is  circumscribi'd,  aiul  has  a  spher- 
oid form  as  long  as  the  choroidal  capsule  remains  unl)r()ken.  Some- 
times it  assumes  a  cake-like  shape,  and  occasionally  tiie  form  of  a 
mushroom.  Rarely,  there  is  diffuse  sarcomatous  infiltration  of  the 
choroid. 

Sarcoma  ol  the  choroid  is  .ijiiiust  iiivari;il)l\-  ;i  prim;iry  growth; 
but  the  choroidal  coal  may  be,  though  very  r;irel\-,  alTected  by  a  metas- 
tasis occurring  from  a  tumor  in  some  other  poitioii  (»f  the  body  for 
example,  the  mediastiiumi  (.\.  \  .  Meigs  and  the  ;mthor,  Wiener). 

The  t  unior  develops  t'i'oiil  I  he  outer  l;iyers  ot   the  eiiolditl.  ;ind  gldWS 


TUMORS    OF    THE    CHOROID 


389 


inward,  detaching  the  retina.  The  cells  are  round  or  spindle  formed  or 
occasionally,  of  a  large  endothelioid  type,  provided  they  develop  from 
the  endothelial  linings  of  the  lymph-spaces.  They  are  usually  pig- 
mented, the  density  of  the  pigmentation  depending  upon  the  partici- 
pation of  the  choroidal  stroma  cells  in  the- proliferative  process.  Usu- 
ally there  are  many  broad  vessels  around  which  the  cells  may  be  grouped. 
Intra-ocular  sarcomas  may  undergo  necrosis  from  insufficient  oxyge- 
nation owing  to  the  death  of  groups  of  cells  at  a  distance  from  blood- 
vessels. Toxins  are  liberated  which  devitalize  the  surrounding  cells 
(Fuchs).  In  the  second  stage  secondary  glaucoma  occurs,  and  oc- 
casionally plastic  iridocyclitis  appears  and  results  in  atrophy  of  the 
globe.     A  tumor  may  grow  in  a  phthisical  eye,  and,  as  Leber  has  pointed 


Fig.     172. — Pigmented    sarcoma    at    a; 
retina  detached  and  folded. 


Fig.  173. — Leukosarcoma  at  a;  retina 
detached. 


out,  an  eye  which  is  the  seat  of  a  growth  may  become  phthisical  and 
the  tumor  itself  cease  to  grow  for  a  time.  Coppez  divides  the  pri- 
mary new  growths  of  the  choroid  into — (1)  Interfascicular  endothelio- 
mas which  develop  from  the  endothelial  cells  of  the  lymph-spaces;  (2) 
peritheliomas  (angiosarcomas)  which  arise  from  the  perithelial  cells  of 
the  blood-vessels;  (3)  sarcomas  of  various  characters  which  grow  from 
the  proper  cells  of  the  choroid  and  the  adventitia  of  the  blood-vessels. 
Alveolar  sarcomas,  also  called  endotheliomas  or  intravascular  angio- 
sarcomas, are  rare  as  compared  with  perivascular  sarcomas  of  the 
choroid.  It  is  probable  that  in  these  alveolar  types  the  greater  mass 
of  the  tumor  is  formed  by  the  proliferation  of  endothelial  cells. 

Diffuse  sarcomas  of  the  choroid  are  classified  by  Parsons  into  two 
subgroups — flat  sarcomas  and  ring  sarcomas.  They  are  characterized 
by  an  infiltrating  tendency,  as  opposed  to  the  formation  of  a  definite 
tumor.  They  exhibit  large  round  or  polygonal  cells,  alveolar  or  plexi- 
form  arrangement,  hyaline  and  myxomatous  degeneration,  and  exten- 


390  DISEASES    OF   THE    CHOROID 

sion  along  the  perivascular  Ij-mph-spaces.  According  to  Parsons,  thej' 
should  bo  considered  as  endotheliomas,  and  they  spring  from  the  lining 
cells  and  proliferate  in  the  spaces  which  they  hne.  The  onset  of  glau- 
coma is  earl}^  in  difTuse  sarcoma. 

Parsons  has  also  called  attention  to  certain  anomalous  sarcomas  of 
the  choroid  which  bear  a  microscopic  similarity  to  organizing  blood-clot 
and  are  of  comparatively  low  malignancy.  According  to  him,  if  they 
are  not  excised,  they  shrink,  and  represent  the  tumors  before  referred  to 
which  have  been  found  in  phthisical  ej'es.  Destructive  hemorrhage 
may  occur  in  choroidal  sarcomas,  as  has  been  specially  pointed  out  by 
^'erhoeff.  Hemorrhages  of  this  character  may  be  responsible  for  the 
sudden  attacks  of  glaucoma  which  are  often  seen  in  choroidal  sarcoma. 
Although  melanoma  of  the  choroid,  that  is,  a  small  cu'cumscribed  mass 
of  chromatophores,  ma}^  occur  (usually  only  accidentally  found 
in  microscopic  examination)  and  not  develop  into  a  sarcoma,  such 
an  origin  has  been  reported,  for  example,  by  the  author  and  Dr. 
Shumway.  The  smallest  sarcomas  on  record  have  been  described  by 
Fuchs  (in  one  instance  the  growth  being  between  0.7  and  0.8  mm.  in 
the  horizontal  and  vertical  diameters),  and  Shumwaj'  and  the  author 
have  also  observed  a  very  small  sarcoma  of  the  choroid  (4.4  mm.  in  the 
anteroposterior  diameter  and  0.9  mm.  in  thickness). 

Symptoms, — The  life  history  of  a  sarcoma  of  the  choroid  has  been 
divided  by  systematic  writers  into  four  periods:  The  first,  the  quiet 
period;  the  second,  the  inflammatory  period;  the  third,  the  extra-ocular 
period,  or  that  stage  when  the  growtli  bursts  through  the  scleral  bound- 
ary; and  fourth,  the  period  of  metastasis. 

In  the  first  stage  the  disease  resembles  a  detachment  of  the  retina, 
this  membrane  being  pushed  forward  by  the  underlying  elevation,  the 
whole  being  surrounded  by  a  serous  effusion.  Beneath  this  retinal 
covering  the  brownish  mass  may  sometimes  be  recognized,  covered  by 
irregular  choroidal  vessels,  except  in  the  non-pigmented  varieties.  If 
the  growth  is  situated  far  forward,  it  is  sometimes  possible  to  examine 
it  by  means  of  obli(iue  illumination  through  a  dilated  jnipil.  There  is  a 
corresj)onding  defect  in  the  field  of  vision,  and  the  sight  of  the  affected 
eye  is  diminished  in  accordance  with  the  situation  of  the  tumor. 
Should  this  be  peripheral,  the  central  vision  at  this  stage  may  not  be 
.seriously  affected.  The  first  stage  usually  lasts  from  six  to  twelve 
months,  but  I'arciy  may  be  jirolonged  to  five  years.  Occasionally  sar- 
(•on)a  of  the  ciioioid  i)r()(luces  symptoms  rescMubling  tenonitis  (Kipp  and 
the  author). 

In  the  next  jx'riod  (jf  the  history  of  this  growth,  or  the  injlannnatoni 
or  glauco7n(it<)iis  .stage,  sym])toms  of  incnvised  tension  which  depend 
u])()n  alterations  in  the  angle  of  tlie  anterior  chamlx'r  aris(>:  pain  in  the 
brow,  anesthesia  of  flie  corneji,  sliallowing  of  the  anterior  chamber,  and 
dilatation  and  loiluosity  of  the  jierforating  episcleral  ve.s.sejs.  Oph- 
thalmoscoi)ic  examination  is  no  longer  po.ssible,  the  localizetl  deiacli- 
nient  of  the  retina  becomes  general  by  increased  .serous  efTusion.  (he 
lens  ni.ay  become  (•;il:ir:ictous,  and  a  se\'ere  iridocyclitis  may  sui)ervene. 


i 


TUMORS  OF  THE  CHOROID  391 

As  the  growth  continues,  the  sclera  is  ruptured  and  the  surround- 
ing tissues  are  involved  {fungus  state  or  stage  of  episcleral  tumors). 
It  may  pass  backward  into  the  brain,  or  secondarily  affect  the  optic 
nerve,  but  more  commonl}'  the  last,  or  metastatic  stage  {stage  of  generali- 
zation), develops;  distant  organs  are  attacked  by  growths  of  similar 
histologic  character,  the  hver  far  more  frequently  than  other  organs, 
but  also  the  spleen,  intestines,  and  even  the  lungs.  ^Metastasis  to  the 
liver  need  not  necessaril}'  be  delayed  until  the  tumor  has  burst,  at  least 
visibly,  through  the  scleral  boundary.  The  most  extensive  secondary 
sarcoma  of  the  hver  which  has  come  under  the  writer's  notice  developed 
from  a  small  sarcoma  of  the  choroid,  apparently  entirely  confined 
within  the  scleral  covering. 

•  Diagnosis. — It  is  necessary  to  differentiate  sarcoma  of  the  choroid 
from  glioma  of  the  retina.  To  this  reference  will  be  made  in  a  future 
section. 

In  the  early  stages  choroidal  sarcoma  may  be  mistaken  for  idio- 
pathic detachment  of  the  retina,  detachment  of  the  choroid  or  sub- 
retinal  exudations  (A.  Knapp,  Friedenwald) .  In  retinal  detachment 
there  is  usually  a  history  of  sudden  onset,  and  the  ophthalmoscope 
may  reveal  undulations  of  the  folds  of  the  detached  retina  with  the 
movements  of  the  eye,  vitreous  opacities,  and  signs  of  choroiditis. 
Moreover,  the  field  is  frequently  less  sharpl}^  defective  than  in  choroidal 
sarcoma.  Inasmuch  as  earlj^  detachment  of  the  retina  occurs  in  many 
cases  of  sarcoma  of  the  choroid,  all  apparently  simple  detachments  of 
the  retina  should  be  most  carefully  studied,  especially  by  means  of 
transilhimination  {diaphanoscopy) .  Various  instruments  have  been  de- 
signed, notably  those  of  Leber,  Sachs,  and  Wtirdemann.  The  eye 
having  been  cocainized,  the  point  of  the  instrument  is  passed  over  all 
areas  of  the  exposed  sclera.  In  the  absence  of  a  growth  the  red  glare 
in  the  pupil  remains  undisturbed  and  bright;  if  a  growth  exists,  the 
passage  of  the  light  is  obstructed  as  the  point  of  the  instrument  is 
placed  over  the  region  beneath  which  it  is  situated,  and  the  pupil 
remains  dark.  In  order  to  detect  tumors  situated  far  posteriorly, 
Lancaster  has  mounted  a  small  Tungsten  lamp  at  the  end  of  a  flexible 
copper  tube  attached  to  a  posterior  flashlight  battery.  Through  an 
incision  in  the  conjunctiva  and  capsule  of  Tenon  the  lamp  can  be 
carried  behind  the  eyeball  and  its  posterior  segment  thus  trans- 
illuminated.  The  value  of  ophthalmodiaphanoscopy  in  these  circum- 
stances has  been  described  on  page  115. 

Choroidal  detachment  is  rare,  the  historj-  is  different  from  that  of 
sarcoma,  and  the  characteristic  vessels  of  the  choroid  can  usually  be 
recognized  beneath  the  vessels  of  the  retina. 

Too  much  reliance  cannot  be  placed  upon  the  tension  of  the  eyeball 
as  a  distinguishing  sign  between  sarcoma  and  retinal  detachment,  be- 
cause intra-ocular  tension  may  be  unaltered  in  each  instance,  although, 
as  C.  Devereux  ^Marshall  has  shown,  it  is  probably  never  diminished 
(as  it  often  is  in  retinal  detachment)  in  undoubted  cases  of  choroidal 
sarcoma,  while  it  may  be  reduced  in  cases  of  sarcoma  of  the  ciliary  body. 


392  DISEASES    OF   THE    CHOROID 

In  the  Stage  of  increusi'd  pressure  the  disease  may  be  distinguished 
from  glaucoma  bj'^  the  history  of  the  case,  by  testing  the  eye  with  a 
transinuminator.  and  by  instilling  a  miotic,  which  in  ordinary  acute 
glaucoma  should  be  more  effective  than  in  an  eye  containing  a  sarcoma 
in  the  glaucomatous  stage.  An  eye  in  the  state  of  absolute  glaucoma 
should  i^lways  be  carefully  examined  in  view  of  the  fact  that  it  may 
contain  a  morbid  growth. 

Pseiuh-tumors  of  the  uveal  trad  should  always  be  considered,  as 
choroidal  and  retino-choroidal  exudation,  subretinal  exudation  and 
massive  retinal  exudation  have  been  mistaken  for  sarcoma.  Repeated 
examinations  are  required  to  decide  the  diagnosis. 

Prognosis. — Removal  of  an  eye  for  choroidal  sarcoma  results  in  a 
ciue  in  from  25  to  30  per  cent,  of  the  cases,  although  statistics  on  this 
point  vary  greath'.  Hirschberg's  published  statistics  may  l)e  briefly 
summarized  as  follows:  Local  recurrence,  2.5  per  cent.;  metastasis, 
41.5  per  cent.;  cure,  56  per  cent.  He  points  out  that  statistics  show 
a  steady  improvement  in  so  far  as  permanent  recover}'  after  enucleation 
for  sarcoma  of  the  choroid  is  concerned.  His  own  earlier  operations 
yielded  only  35  per  cent,  of  recoveries.  ^letastasis  to  internal  organs 
is  the  most  usual  cause  of  death  and  generally  takes  place  within  two 
years  after  operation.  The  stage  at  which  enucleation  is  performed 
does  not  certainly  influence  the  occurrence  of  metastasis,  although,  as 
Hirschberg  maintains,  operation  at  the  very  earliest  stage  siiould 
be  urged.  It  is  usually  stated  that  very  vascular  and  round-celled 
sarcomas  are  more  fatal  than  other  varieties.  Prognosis  is  better  in 
young  than  in  aged  subjects.  Local  recurrence  is  much  less  frequent 
than  metastasis;  it  is  prevented  by  promi)t  removal  of  the  eye.  If  there 
is  no  recurrence  or  metastasis  within  four  years  after  enucleation  of  the 
eye,  this  complication  becomes  unlikely,  although  exceptions  to  this  rule 
have  occurred,  and  metastasis  has  been  noted  even  after  seven  years.  || 

Treatment. — From  what  has  been  said  it  is  evident  that  the  only 
treatiuciit  is  prom])t  enucleation.  The  optic  nerve  should  be  severed 
as  far  back  in  the  orbit  as  is  possible.  It  may  be  necessary  to  remove 
the  entire  contents  of  the  orbit.  The  treatment  of  choroidal  sarcoma 
by  radium  has  not  yielded  very  satisfactory  results. 

Rare  forms  of  tumor  of  the  choroid  are  the  following:  ('(ucrnous 
angioma,  tclatujiectatic  .sarcoma,  adenoma,  and  cnchondromii.  Angiomas 
of  the  choroid  (al)oul  21  are  on  record)  ni;iy  occur  in  connection  with 
nevi  of  the  face. 

Carcinoma  of  the  Choroid. — The  tumor  (a  com))ai:ili\  cly  raie 
growth.  al)out  onc-tiiird  being  bilaleral)  is  of  rapid  development  ami 
generally  appeals  as  a  Hat  growth  in  the  neighl)oiliood  of  tlu'  macula. 
In  tlie  majority  of  instances  it  represents  a  metastasis  from  a  carcinoma 
of  the  mammary  gland  (35)  times  in  M  cases  collected  by  Suker  and 
(.Irosvener);  the  piimaiy  neoplasm  has  also  been  situateil  in  the  lungs, 
pleura,  stonnich,  liver,  thyroid,  mediaslin.al  glands,  suprarenal  glami, 
prostate,  and  ovary.  The  metastasis  takes  place  through  the  posterior 
ciliary  arteiies  anil  later  deNclops  in  the  |)eri\ascular  l\niph  sjiaces. 


TUBERCLE  OF  THE  CHOROID 


393 


Tubercle  of  the  Choroid. — Tubercles  appear  in  the  choroid  as 
yellowish-white  spots,  varying  in  size  from  1  to  1.5  mm.,  occasionally 
larger,  and  usually,  though  not  necessarily,  associated  with  similar 
growths  in  the  meninges  (tuberculous  meningitis).  Repeated  ex- 
amination is  required  for  their  detection,  and  even  then  they  may  es- 
cape observation,  owing  to  their  diminutive  size  {choroidal  dust). 
The  facility  of  their  detection  has  been  much  enhanced  since  the  in- 
troduction of  electric  ophthalmoscopes.  They  have  been  frequently 
found  in  postmortem  examinations. 


Fig.    174. — Tubercles  in  the  choroid. 

Tubercles,  known  as  miliary  tubercles,  are  distinguished  chiefly  by 
their  color,  which  has  been  described  as  of  a  dull  yellowish  white  in  the 
center,  encircled  by  an  ill-defined  rose-colored  area  (Horner).  Usually 
there  are  no  pigmentary  changes  in  the  immediate  neighborhood,  but 
pigment  bodies  may  surround  the  nodules  if  they  are  prominent  (Bach). 
They  are  situated  usually  near  the  optic  disk  or  in  the  macular  region, 
and  vary  in  number  from  three  to  six  or  many  more.  Optic  neuritis  and 
tubercles  in  the  choroid  may  develop  at  the  same  time  during  meningitis. 

Instead  of  the  miliary  growth,  a  single  large  tuberculous  tumor  may 
appear  and  progress,  producing  the  same  destructive  changes  as  a  sar- 
coma.    It  may  be  associated  with  a  similar  one  in  the  brain. '^     Accord- 

^  Chronic  choroidal  tuberculosis  is  characterized  by  optic  neuritis,  optic  atrophy 
hemorrhages  (tuberculous  inflammation),  and  a  diffuse,  j'ellowish-white  discolora- 
tion, occupying  a  considerable  area  of  the  eye-ground,  within  which  are  round, 
yellowish-white  spots.  Michel  described  tuberculous  granulation  tumors  of  the 
choroid,  which  began  with  the  appearance  of  retinal  detachment,  and  later  caused 
abscess  in  the  vitreous  and  shrinking  of  the  eye. 


394 


DISEASES    OF    THE    CHOROID 


ing  to  Zur  Xedden,  the  age  of  patients  suffering  from  tuberculous 
tumor  of  the  choroid  has  varied  between  one  and  a  half  and  sixty-two 
years,  although  the  age  of  childhood  has  furnished  by  far  the  greatest 
percentage.  The  condition  must  be  differentiated  from  glioma  of  the 
retina  in  the  young  and  sarcoma  of  the  choroid  in  adults.  The  evolu- 
tion of  conglomerate  tubercle  of  the  choroid  is  usually  more  rapid  than 
that  of  tumor.  Scleral  involvement  and  perforation  generally  occur 
early  in  the  disease.  Choroidal  tuberculosis  is  rarely  primary.  Other 
signs  of  tuberculosis  will  usually  be  found  in  the  general  system.  Occa- 
sionally in  eye-grounds  otherwise  normal,  and  in  patients  in  good 
health,  isolated  areas  of  choroidal  atrophy  with  or  without  pigment 
heaping,  or  large  patches  of  dense,  slightly  elevated  pigment  are  seen, 
which  probably  represent  healed  tuberculous  lesions — the  so-called 
obsolescent  tubercles  or  tuberculous  areas. 


Fio.  175. — Rupture  of  the  choroid  on  the  temporal  side  of  the  disk  and  pigmented 
traumatic  choroiditis  (see  page  379)  on  the  nasal  side  (from  a  patient  under  the  care  of 
Dr.  Randall  in  the  Children's  Hospital). 

Treatment. — Miliary  tubercles  of  the  choroid  do  not  require  any 
treatment  directed  to  the  eye  itself,  the  vision  of  which  maj'  not  be 
seriously  affected.  If  a  single  large  choroidal  tumor  is  recognized, 
and  the  patient's  general  condition  jiermits  it,  enucleation  to  avert 
general  tuberculosis  would  seem  to  be  a  proper  procedure.  Instead  of 
surgical  procedures,  injections  of  tuberculin  (T.  R.)  have  been  em- 
ployed by  von  Hippel  and  others  with  encouragiug  results,  and  should 
be  given  full  trial  (see  also  ])age  'M)~)). 

Injuries  of  the  Choroid.  Wounds  of  the  Choroid. — Neces- 
sarily, in  a  perforating  wound  of  the  sclera,  the  choroid  is  also  lacerated 
or  incised,  and  no  description  other  than  that  already  given  in  this 
connection  is  reciuired. 

Foreign  Bodies  in  the  Choroid.  \  foreign  body,  usually  metal,  may 
lodge  in  the  clKnoid;  the  treatment  has  been  tlescril»ed  on  pages  319 
and  320. 


DETACHMENT  OF  THE  CHOROID  395 

Rupture  of  the  Choroid. — The  most  important  injury  to  which  the 
choroid  is  subject,  and  which  follows  a  blow  upon  the  eye,  is  rupture. 
This  generally  manifests  itself  in  a  sickle-shaped  crescent,  commonly  on 
the  temporal  side  of  the  disk,  rarel}^  on  the  nasal  side,  and  which  very 
seldom  extends  in  a  horizontal  direction.  The  rupture  may  be  single 
or  multiple,  and  sometimes  is  composed  of  several  branches.  The 
immediate  effect  of  the  blow  is  a  hemorrhage  preventing  distinct 
observation.  After  its  disappearance  the  fissure  is  evident  to  the 
ophthalmoscope  as  a  yellowish-white  stripe  bordered  with  some  dis- 
turbed pigment  (Fig.  175).     (See  also  page  652.) 

The  ruptures  usually  run  concentrically  with  the  papilla. 
They  may  be  either  complete  or  incomplete,  and  may  or  may  not 
be  associated  with  breakage  of  the  overlying  retina.  In  rupture  con- 
fined to  the  choroid,  the  retinal  vessels  pass  over  it.  If  the  retina  has 
also  given  way  there  is  apt  to  be  more  hemorrhage  than  without  such 
accident,  and  no  retinal  vessels  are  observed  crossing  the  choroidal 
separation.  Associated  with  choroidal  rupture  there  may  be  a  rupture 
of  the  sphincter  of  the  iris  (Duane  and  the  author) . 

The  ultimate  effect  of  vision  depends  upon  the  size  and  situation 
of  the  rupture.  At  first  there  is  very  considerable  disturbance  of 
sight,  partly  due  to  effusion  and  partly  to  injury  of  the  iris,  sometimes 
associated  with  blood  in  the  anterior  chamber.  This  slowly  clears  away  . 
and  very  good  vision  may  result  provided  the  change  in  the  eye-ground 
has  not  been  extensive.  A  deterioration  of  vision  may  occur  a  long  time 
after  such  an  injury  owing  to  secondary  changes  in  the  optic  nerve. 

Treatment. — The  pupil  should  be  dilated  with  atropin;  if  there  is 
much  pain,  a  leech  or  two  should  be  applied  to  the  temple,  a  pressure 
bandage  adjusted,  and  the  patient  put  to  bed.  These  measures  suffice 
to  encourage  the  absorption  both  of  the  blood  and  of  the  serous  effusion. 
Hemorrhage  into  the  Choroid. — In  the  section  on  Unclassi- 
fied Forms  of  Choroidal  Disease  variously  shaped  hemorrhages  which 
appear  in  this  membrane,  and  which  by  absorption  give  rise  to  atrophic 
spots,  have  been  described.  In  like  manner  there  may  be  hemorrhage 
from  the  choroid,  the  result  of  a  blow.  A  choroidal  hemorrhage  may 
be  distinguished  from  one  situated  in  the  retina  by  noticing  the  more 
diffuse  character  of  the  extravasation  and  the  fact  that  the  retinal 
vessels  pass  over  it,  but  the  diagnosis  is  difficult. 

Detachment  of  the  Choroid. — This  is  a  comparatively  rare 
clinical  condition,  although  not  infrequently  found  in  enucleated, 
shrunken  eyes.  It  may  be  spontaneous  or  traumatic,  partial  or  com- 
plete. The  detachment  may  be  caused  by  blood,  serum,  a  layer  of 
lymph,  or  a  new  growth.  Cases  following  cataract  extraction,  iridec- 
tomy for  glaucoma,  iridosclerectomy,  and  corneoscleral  trephining  (see 
page  705)  are  not  very  uncommon.  The  detached  choroid  protrudes 
as  a  dark  mass  into  the  vitreous,  and  the  antei'ior  chamber  is  shallow 
or  obhterated.  It  is  caused  by  the  passage  of  the  aqueous  humor 
through  a  rent  in  the  attachment  of  the  cihary  body  beneath  the 
choroid.     The  prognosis  generally  is  favorable. 


396  DISEASES    OF   THE    CHOROID 

Mcller,  who  has  carefully  studied  the  suliject.  classifies  detachment 
of  the  choroid  thus:  Early  postoperative  detachment,  innocent  in  char- 
acter; late  postoperative  detachment,  following  trauma  or  occurring 
without  cause;  spontaneous  detachment,  either  innocent,  reseml)ling 
postoperative  separation,  or  malijinant,  causin};  hlindness.  If  the  ret- 
ina is  detached  with  the  choroid  the  prognosis  is  most  unfavorable. 

Ossification  of  the  Choroid. — This  is  occasionally  found  in  eyes 
long  blind  and  shrunken  from  destructive  iridochoroiditis.  The  forma- 
tion of  bone  occurs  in  the  infianunatory  tissue,  and  may  be  recognized 
by  palpation  in  the  form  of  an  irregular  plate,  spicule,  or  complete  shell. 
Calcareous  degeneration  is  common  in  eyes  of  this  character.  The  eye- 
ball should  be  enucleated. 

Atrophy  of  the  eyeball  is  a  condition  characterized  by  diminu- 
tion in  the  size  of  and  by  alteration  of  the  shape  of  the  glol)e.  caused  by 
contraction  of  inflammatory  exudations — for  example,  those  formed  in 
the  uveal  tract,  or  in  the  vitreous,  followed  by  detachment  of  the 
retina.  The  eyeball  is  somewhat  quadrate  in  shape  and  grooved  by 
the  pressing  action  of  the  recti  muscle.  The  cornea  is  small ;  it  may 
be  opaciue,  but  sometimes  is  quite  clear  and  protuberant.  The  iris 
is  atrophic.  It  should  be  sharply  distinguished,  as  Fuchs  points  out, 
from  phthisis  hulbi,  which  results  from  a  suppurative  inflammation 
(see  page  386)  and  is  associated  with  rupture  of  the  sclera  antl  partial 
evacuation  of  the  ocular  contents.  Such  an  eyeball  shouUl  l)e  re- 
moved; sometimes  it  produces  sympathetic  irritation. 

Hypotony,  the  reverse  of  elevation  of  tension  (hypertonia),  which 
in  most  of  its  aspects  has  been  considered  in  the  previous  chapter, 
occurs  under  many  conditions,  to  some  of  which  reference  has 
been  made.  It  is  conveniently  discuss(Hl  in  this  jilace.  Diminished 
intra-ocular  pressure  is  a  constant  symptom  after  perforation  of  a 
corneal  ulcer,  in  association  with  a  fistulous  scar  or  a  corneal  fistula, 
following  escape  of  vitreous  as  the  result  of  penetrating  wounds  of  the 
sclera,  etc.  (page  317).  Hypotony  may  be  due  to  a  violent  contusion  of 
the  eye,  without  rupture  of  the  ocular  coats,  l)ut  associated  with  grave 
internal  lesions — vitreous  disorganization  and  hemorrhage,  rupture  of 
the  choroid,  detachment  of  the  retina,  etc.  It  may  be  a  symptom  of 
paralysis  of  the  sympathetic.  In  diabetic  coma  the  eyel)all  may  be 
soft,  usually,  but  not  invariably,  a  sign  of  (>vil  prognostic  import.  It 
does  not  occur  insiiuple  dial)etes  or  acidosis  without  coma  tKiesman). 

Ophthalmomalacia  {essential  phthisis  hnlhi)  is  the  name  a])plietl 
to  a  condition  of  the  eye  charact(>rize(l  by  hy|)otony  (softening)  and 
diminution  in  its  size  which  may  appear  spontaneously  and  is  uiH(>lateil 
to  in(l;iinnialion.  Tlieic  may  be  photoiiiiobia,  ])ain,  miosis,  and  droop- 
ing of  the  u])i)ei'  lid.  PIk'  condition  may  last  lOi'  a  few  hours  only  or 
for  several  <lays.  I'suallN' tliere  is  a  return  to  the  normal  conditions. 
An  intermittent  varietN'  has  Iti-cii  (les<'iibi-d.  It  may  follow  injury  and 
has  been  attriliuled  |o  disease  of  the  s\  lupat  liel  ic. 


CHAPTER  XII 
GLAUCOMA 

Glaucoma  is  the  name  applied  to  a  disease  the  essential  symp- 
toms of  which  in  its  various  manifestations  depend  upon  increased 
intra-ocular  tension. 

Varieties  of  Glaucoma. — Systematic  writers  are  accustomed  to 
divide  glaucoma  into  (1)  primary  glaucoma,  or  that  form  which  arises 
independently  of  clinically  evident  antecedent  disease  of  the  eye,  and 
(^"secondary  glaucoma,  or  that  form  which  occurs  as  the  sequel  of  a 
pre-existing  ocular  disease,  often  an  inflammation  of  theoiveal  tract. 

The  primary  variety  of  this  disease  has  been  divided  into  (1) 
acute  congestive  glaucoma  (acute  inflammatory  glaucoma) ;  (2)  sub- 
acute congestive  glaucoma  ("glaucoma  irritatif,"  chronic  congestive 
glaucoma);  (3)  chronic  non-congestive_ glaucoma  (simple  glaucoma, 
glaucoma  simplex). 

For  clinical  purposes  it  is  convenient  to  retain  these  varieties  of 
glaucoma  and  their  descriptive  names,  but  it  should  be  distinctly  re- 
membered that  in  a  certain  sense  the  divisions  are  artificial,  because  an 
acute  glaucoma  may  cease  to  have  its  congestive  character  and  take  on 
the  signs  which  are  ordinarily  supposed  to  indicate  the  chronic  variety 
of  the  disease,  and  the  so-called  glaucoma  simplex  may  at  any  stage  of 
its  career  develop  symptoms  of  an  acute  progress,  and  lose  its  non- 
congestive  character. 

Symptoms. — The  following  is  a  syllabus  of  the  symptoms  common 
to  the  disease  glaucoma,  although  all  of  these  symptoms  are  not  con- 
stantly present  in  each  variety. 

1.  Rise  in  intra-ocular  tension,  or  increased  hardness  of  the  eyeball. 
Formerly  variations  in  the  intra-ocular  pressure  were  designated  by 
the  symbols  T?  ("stiffened  sclera")  to  T  +  3  ("stony  hardness"). 
Intermediate  degrees  were  expressed  T  +  1  and  T  +  2. 

Since  the  introduction  of  satisfactory  tonometers,  particularly  the 
instrument  of  Schiotz,  the  crude  estimation  of  the  impressibility  of  the 
eyeball  by  means  of  finger  palpation  has  given  place  to  the  tonometer 
(page  90) ;  it  measures  the  impressibility  of  the  eyeball  from  the  degree 
of  which  the  intra-ocular  pressure  is  inferred.  In  the  absence  of  an 
instrument  of  precision  finger  palpation  of  the  globe  must  be  utilized 
and  the  student  should  by  practice  train  his  fingers  in  this  regard. 

2.  Change  in  the  Size  and  Shape  of  the  Pupil  and  Mobility  of  the 
Iris. — The  pupil  may  be  round,  but  usually  is  oval  or  egg  shaped,  with 
the  long  axis  vertical;  it  may  be  semidilated,  or  expanded  to  its  fullest 
limit;  the  iris  is  sluggish  in  movement  or  entirely  inactive. 

The  pupillary  space  sometimes  transmits  a  greenish  reflex  (hence 
the  name  given  by  the  older  writers)  from  the  surface  of  the  lens.     The 

397 


398  GLAUCOMA 

dilatation  of  the  pupil  is  explained  by  paresis  of  the  ciliary  nerves  or 
by  constriction  of  the  vessels  of  the  iris.  Partial  atrophy  of  the  lesser 
circle  of  the  iris,  which  may  lead  to  permanent  dilatation  of  the  pupil, 
is  not  uncommon  after  acute  attacks  of  increased  tension  (Hirschberg). 

3.  Loss  of  the  Transparency  of  the  Cornea. — The  cornea  somewhat 
resembles  the  appearance  of  glass,  the  surface  of  which  has  been  dulled 
by  beinK  breathed  upon.     This  haziness  is  marked  in  the  congestive 
types  of  glaucoma,  but  is  absent  or  only  slightly  present  in  the  non-^ 
congestive  varieties.     If  the  cornea  is  carefully  examined,  the  cloudi-  '' 
ness  will  be  found  more  decided  in  the  center,  and  will  resolve  itself 
into  very  numerous  closely  aggregated  points,  the  whole  presenting  a  • 
stip})lod   or   "needle-stuck"   appearance.     Iritis   and   iridochoroiditis 
may  produce  a  similar  appearance.     The  condition  has  been  attributed  ■ 
to  an  edema  of  the  cornea.     Loss  of  corneal  transparency  with  in- 
creased intra-ocular  tension,  such  as  may  be  cau.sed,  for  example,  by* 
external  pressure  on  the  eye,  is  due,  according  to  v.  Fleishl,  to  th^  f 
corneal  fibers  becoming  doubl}'  refracting. 

4.  Change  in  the  Depth  of  the  Anterior  Chamber. — This  symptom 
varies  from  an  almost  imperceptible  shallowing  to  a  complete  oblitera- 
tion. During  the  course  of  glaucoma  the  lens  sj'stem  and  peripheral 
portion  of  the  iris  are  pushed  forward,  and  this  causes  the  lessening  of 
the  depth  of  the  anterior  chamber. 

5.  Change  in  the  Normal  Appearance  of  the  Iris  and  Turbidity  of  the 
Aqueous  and  Vitreous. — The  same  edema  which  affects  the  cornea  may 
also  cause  loss  in  the  characteristic  markings  of  the  iris,  so  that  its 
pattern  becomes  indistinct,  especially  in  congestive  forms  of  glaucoma. 
The  veins  of  the  iris  may  be  dilated  and  tortuous;  small  hemorrhages 
are  sometimes  visible.  Opacities  in  the  media  also  are  liable  to  form, 
and  the  lens  itself  may  become  cataractous. 

6.  Alterations  in  the  Conjunctival  and  Episcleral  \'cssels. — In  acute 
glaucoma  there  are  usually  general  hyperemia  and  often  edema  of  the 
conjunctiva,  but  in  chronic  congestive  and  sometimes  even  in  non- 
congestive  glaucoma  there  are  marked  enlargement  and  tortuosity  of 
the  episcleral  venous  l)ranches  (see  System  11,  page  49). 

7.  The  Excavation  of  the  Nerve-head  and  the  Surrounding  Ydlou'i.^h 
^'Halo,"  or  "Glaucomatous  Ring." — Under  the  influence  of  the  increased 
intra-ocular  pressure  the  nerve  bundles  give  way,  the  lamina  cribrosa 
recedes  and  the  glaucomatous  cup  is  jiroduced.  According  to  Knies, 
congestion  and  edema  of  the  nerve-licad  i)re{'ede  cupijing,  and  accord- 
ing to  liiailcy  and  I'lthnunds,  actual  neuritis  :i])p('ars  in  advance  of 
increased  tension.  The  author  and  (lasjjarrini  have  seen  glaui-omatous 
excavation  of  the  papilla  follow  retrobulbar  neurit  is.  N\  ahlfors  denies 
that  increa.sed  intra-ocular  tcMision  alone  is  suflieient  to  cau.*<e  cui)ping 
of  lh(!  n(;rve-liea<i,  iiiasiiiiich  as  it  requires  a  i)ressur(>  of  liif)  mm.  of 
nuMTury  to  jjroduce  sudi  an  excavation,  and  in  glaucoma  the  ri.se 
rarely  exceeds  100  immi.  According  to  liim,  :itroi)hy  of  the  choroid  is  an 
important  factor  in  this  respect,  because  tlie  resistance  of  tiu*  Lamina 
cribros.'L  is  llilis  re(hlce(|,  owing  to  inlerfeience  with  the  \-essel-l)e;iring 


Plate  III. 


The  fundus  of  an  eve  with  chronic  glaucoma. 


NERVE-HEAD    IN    GLAUCOMA 


399 


tracts  which  pass  from  the  surrounding  choroid  into  the  nerve-trunk 
and  branch  in  the  anterior  layers  of  the  lamina.  According  to  Schna- 
bel,  the  excavation  in  the  nerve-head  in  glaucoma  does  not  depend 
upon  increased  inti'a-ocular  tension,  but  upon  a  form  of  degeneration 
of  the  optic  nerve-fibers,  which  causes  their  complete  disappearance 
and  the  formation  of  small  cavities,  both  anterior  and  posterior 
to  the  lamina  cribrosa  {cavernous  atrophy  of  the  optic  nerve).  Lacunar 
atrophy  of  the  optic  nerve,  however,  has  also  been  observed  in  myopia 
without  hypertony  and  is  often  not  found  in  eyeballs  which  have 
long  been  the  subjects  of  increased  tension.  There  is  little  or  no 
doubt  that  cupping  of  the  nerve-head  in  glaucoma  should  be  attributed 
to  the  direct  influence  of  the  increased  pressure  within  the  eyeball. 

Axenfeld  and  other  observers  have  witnessed  retrogression  of  a 
glaucomatous  excavation,  complete  retrogression  being  rare,  but  the 
partial  variety  is  not  uncommon.  This  observation  further  indicates 
that  the  excavation  is  due  to  increased  intra-ocular  pressure  and  that 
the  position  of  the  lamina  cribrosa  in  glaucoma  is  not  a  constant  one. 

1.  2 


^'^^^^'^^^ll'-^!^'"'^^^^ 


Fig.  176. — Excavations  in  nerve-head:  1,  Physiologic;  2,  atrophic;  and  3,  glaucoma- 
tous excavations  (from  a  drawing  by  Randall). 

The  cupping  of  the  optic  disk  is  seen  with  the  ophthalmoscope,  and 
its  depth  is  measured  according  to  the  directions  given  on  page  113. 
It  is  also  recognized  by  employing  the  parallax  test  with  the  indirect 
method  as  follows :  The  optic  nerve  is  found  in  the  usual  manner  by  the 
inverted  image,  and  the  object  lens  moved  from  side  to  side.  The  entire 
eye-ground  apparently  moves  with  the  motions  of  the  lens,  and  the 
bottom  of  the  excavation  also  seems  to  move  in  the  same  direction,  but 
at  a  much  slower  rate.  The  contrast  in  the  rate  of  the  two  movements 
is  in  a  direct  ratio  with  the  depth  of  the  excavation. 

The  cup  varies  from  one  beginning  to  be  pathologic  to  a  fully  formed 
excavation.     In  the  latter  instance  the  excavation  is  complete  to  the 


400 


GLAUCOMA 


scleral  margin,  and  its  edges  are  al)rui)t :  the  vessels  are  crowded  to  the 
nasal  side,  bend  sharply  over  the  margin,  and  are  lost  to  view  behind 
the  border  of  the  cup,  reajipearing  in  fainter  color  at  its  bottom. 

The  papilla  is  enciicled  by  a  yellowish  ring  due  to  atrophy  of  the 
surrounding  choroid. 

It  is  important  to  distinguish  between  a  large  physiologic  cup,  an 
excavation  due  to  atrophy  of  the  optic  nerve,  and  the  glaucomatous  cup. 
A  physiologic  excavation  is  partial  and  formed  in  a  normally  tinted 
nerve-head;  an  atrophic  excavation  is  complete,  shallow,  and  formed  in 
a  nerve-head  of  abnormal  whiteness,  owing  to  its  loss  of  capillarity;  and 
a  glaucomatous  excavation  is  complet(\  deep,  and  often  of  greenish  hue. 
The  microscopic  appearances  of  a  nerve-head  containing  a  deep  glau- 
coma cup  are  shown  in  Fig.  177  (consult  also  Fig.  176). 


>• 


Fk;.  177. — Section  of  optic  nerve-head  contuininK  a  deep  glaucomatous  excavation, 
the  so-called  kettle-shaped  excavation:  r,  Retina;  ch,  choroid;  s,  sclera;  c,  cup,  or  ex- 
cavation, pushing  back  lamina  crihrosa. 


The  descriptions  thus  far  given  apply  to  typical  forms  of  each 
variety  of  excavation.  Sometimes  it  is  a  mattcM'  of  considerable  diffi- 
culty to  decide  between  them,  esp(>ciall\  Itetween  an  afrojihic  and  a 
glaucomatous  excavation  where  the  latter  is  shallow;  t)r  lu'tween  a 
physiologic  excavation  and  glaucoMi.-i.  where  llu-  former  is  associated 
with  ))iiniar\'  o])lic  iier\('  atro))hy.  .\  diagnosis  must  then  be  based 
ui)oii  otliec  syiu])tonis,  particularly  an  examination  of  the  tield  of 
vision  (page  402). 

S.  \'r.\s(l  Piilstiliiin  1)11  till  Siirfdct  of  llu  Disk.  {<i)  Thr  \'<iiis. — 
'Inhere  is  often  marked  nciious  pulse,  especially  ;it  the  dark  knuckles  of 
the  ^'eins  as  they  bend  over  the  maigin  of  the  e\ca\ation,  but  this  is  a 
connnon  ophthalmoscopic  .-ippearaiice  in  healthy  eves  (see  pjigc*  lOti), 
;iii<l  lience  caiiiiol   be  iitili/ed  as  a  di;miiostic   symptom. 


VISUAL   ACUTENESS   IN    GLAUCOMA  401 

(6)  The  Arteries. — Pulsation  of  the  arteries  is  a  rare  appearance 
except  in  aortic  regurgitation,  and  therefore  may  be  regarded  as  an  im- 
portant indication  of  increased  intra-ocular  tension,  in  high  degrees  of 
which  it  is  a  striking  s\Tnptom,  the  arterial  trunks  on  the  surface  of  the 
disk  showing  rapid  alternate  filhng  and  collapse.  It  is  usually,  but  not 
always,  confined  to  the  disk.  The  cause  of  spontaneous  arterial  pulsa- 
tion resides  in  the  resistance  to  the  passage  of  the  blood  through  the 
vessels,  a  resistance  which,  in  turn,  depends  parth'  upon  increased  ten- 
sion and  partly  upon  spasmodic  contraction  of  the  vessels  themselves. 
In  cases  of  glaucoma  in  which  this  pulse  is  not  spontaneously  visible  it 
ma}'  be  induced  by  slight  pressure  upon  the  globe. 

In  addition  to  the  objective  signs  of  glaucoma  just  described,  certain 
subjective  symptoms  are  more  or  less  constantly  present. 

1.  Pain. — In  acute  attacks  the  pain  is  a  severe  neuralgia  of  the  tri- 
geminal distribution,  and  often,  in  violent  congestive  cases,  an  intense 
agony  associated  with  great  depression,  pallor  of  the  countenance, 
nausea  and  vomiting.  In  subacute  attacks  there  is  a  less  marked 
similarly  located  pain.  In  chronic  cases  there  may  be  only  a  general 
feeling  of  discomfort,  a  sense  of  fulness,  occasional  shoots  of  neuralgia, 
or  attacks  described  by  the  patient  as  "headache." 

2.  Alteration  in  the  Sensibility  of  the  Cornea. — Anesthesia  of  the 
cornea  varies  from  a  slight  depreciation  in  its  sensitiveness  to  an  entire 
loss  of  sensation,  as  complete  as  that  produced  by  cocain.  Sometimes 
the  anesthesia  is  not  uniform  over  the  surface  of  the  cornea,  but  exists 
in  spots  or  segments.  It  is  due  to  the  edema  of  the  structure,  which 
presses  upon  the  filaments  of  the  corneal  nerves. 

3.  Alterations  in  the  Light  Sense. — Although  it  is  well  known  that 
the  light  sense  is  markedly  affected  in  glaucoma,  the  interpretation  of 
the  results  which  have  been  obtained  are  by  no  means  uniform.  Elliot, 
who  has  designed  a  useful  light  sense  apparatus  for  clinical  purposes, 
quotes  with  approval  the  observations  of  Beauvieux  and  Delorme  thus: 
the  differential  light  sense  (^.  e.,  the  smallest  difference  perceivable  be- 
tween two  illuminated  areas  of  different  intensity)  is  early  attacked,  a 
lessened  acuity  being  observable  prior  to  the  period  when  ophthalmo- 
scopic evidence  is  definite  or  there  is  diminution  of  central  or  peripheral 
vision.  The  absolute  light  sense  (?'.  e.,  the  perception  of  minimal 
stimulus,  or  threshold)  is  lessened  only  after  definite  changes  in  the 
nerve-head  are  evident.  Night-blindness,  although  uncommon,  has 
been  observed,  and  glaucoma  patients  are  unduly  sensitive  to  dimin- 
ished illumination  in  the  ordinary  sense  of  this  term.  The  subjects 
of  simple  glaucoma  in  its  earliest  stages  or  even  when  in  anticipation, 
with  normal  visual  acuteness,  if  tested  with  Bjerrum's  or  de  Wecker's 
photometric  types  will  almost  always  show  a  decided  lessening  of 
acuity  of  sight. 

4.  Alterations  in  Central  Visual  Acuteness. — This  symptom  varies 
considerably,  and  in  chronic  cases  excellent  sharpness  of  sight  may  be 
preserved  for  a  long  time.  It  is  important  to  remember  this,  because  it 
IS  not  safe  to  depend  upon  central  vision  as  a  guide  of  the  rate  of  prog- 

26 


402 


GLAUCOMA 


ress  of  a  chronic  glaucoma.  In  each  attack  of  subacute  glaucoma  the 
vision  quickly  fails,  and  gradually  is  recovered  as  the  attack  passes 
away.  Each  recurrence  leaves  a  more  permanent  impression.  In 
acute  glaucoma  a  characteristic  symptom  is  the  sudden  loss  of  vision, 
which  in  a  few  hours  may  be  reduced  to  a  light  perception,  and  in  cer- 
tain mahgnant  types  rapidly  becomes  extinct. 


Fig.  178. — Chronic  glaucoma,  Bjer- 
rum'e  scotoma  and  Ronne's  nasal  step. 
(After  Elliot,  slightly  modified). 


Fig.  179. — Chronic  glaucoma.  Nar- 
row field  on  temporal  side,  scotoma  pass- 
ing from  blind-spot  (Bjerrum's  sign). 
Vision  %■};  duration  four  years. 


5.  Alteration  of  the  Refractive  Power  of  the  Eye  and  Diminution  of  the 
Amplitude  of  Accommodation. — The  former  depends  upon  the  change 
in  the  shape  of  the  cornea,  and  the  latter  upon  the  effect  of  pressure 
upon  the  ciliary  nerves.  Alterations  in  the  curvature  of  the  cornea  tend 
to  produce  an  astigmatism  "contrary  to  the  rule"  (see  page  147),  hence 


Fio.  180. — Field  of  vision  of  right 
eye  in  a  caso  of  Biihaciite  gluui-Dina. 
Loss  of  the  uusa!  half  and  concentric  re- 
striction of  the  preserved  field. 


FiQ.  181. — Field  of  vision  of  right 
eye  in  a  case  of  iliroiiic  glauconin,  ahow- 
ing  concentric  restriition  of  tlu>  fioUi. 


this  is  an  iin])ortant  event  in  chronic  glaucoma  and  in  ))criods  preceding 
its  development.  Diminished  power  of  accommodation  is  evidenced 
by  the  desire  of  jjatients  to  change  their  reading-glas.s(>s  to  such  as  are 
stronger  than  tlic  degree  of  refractive  error  or  age  of  life  would  warrant. 
0.  Altcralion  in  J'crijihcral  I'/.v/on,  or  the  Field  of  I'ision.  \  careful 
iM.'ip  of  I  he  field  of  vision  in  gl;iiiconi;i  is  indispensable,  and  iherestric- 


VISUAL    FIELD    IN    GLAUCOMA 


403 


tions  present  themselves  in  several  forms :  (a)  The  most  usual  and  typ- 
ical variety  is  partial  or  complete  loss  of  the  nasal  field  or  of  the  upper  or 
lower  quadrant  of  the  nasal  side ;  (6)  concentric  restriction  of  the  entire 
field;  (c)  restriction  so  constituted  that  the  remaining  field  assumes  an 
oval  or  trowel  shape;  (d)  sectional  defects,  often  of  the  superonasal  area; 


Fig.  182. — Field  of  vision  in  right  eye 
in  case  of  chronic  glaucoma,  showing  sec- 
tional defect  (superonasal  quadrant). 


Fig.  183. — Field  of  vision  of  left  eye 
in  chronic  glaucoma.  Trowel-shaped 
patch  preserved  chiefly  on  the  temporal 
side. 


(e)  loss  of  the  entire  field  except  a  patch  on  the  temporal  side;  (/)  the 
formation  of  scotomas,  which  may  be  central,  paracentral,  annular,  or 
peripheral  (Figs.  185-188);  (g)  special  visual  field  defects — Bjerrum's 
scotoma,  Seidel's  sign,  Ronne's  step. 

The  contraction  of  the  color-fields  is  usually  proportionate  to  that 
of  the  form-field,  but  this  rule  meets  with  exceptions.     Under  thein- 


FiG.  184. — From  the  same  case  as 
Fig.  183,  six  months  later;  only  a  small 
patch  of  preserved  field  on  the  temporal 
side. 


Fig.  185. — Just  beginning  contraction 
of  nasal  field;  scotoma  extending  from 
blind-spot  in  a  semicircular  manner  up- 
ward and  inward  (Bjerrum  scotoma). 


fluence  of  operative  measures  or  miotics  very  decided  improvement  in 
the  extent  of  the  visual  field  may  take  place. 

The  tendency  of  the  visual  field  is  to  contract  progressively  as  the 
disease  advances,  and  finally  all  portions  are  obliterated  except  a  small 
part  upon  the  temporal  side,  which  also  disappears  in  the  ultimate 
blindness  (consult  Fig.  184). 


404 


GLAUCOMA 


The  contraction  of  the  field  of  vision  is  an  important  index  of  the 
rate  of  progress  in  glaucoma,  more  important  than  depreciation  of  cen- 
tral vision;  but  it  is  not  sufficient  to  trust  to  the  periphery  of  the  field 
for  information.  A  search  for  scotomas  is  imperative.  They  must  be 
found  either  by  the  method  suggested  by  Bjerrum  or  with  the  aid  of 
a  campimeter,  and  by  means  of  "small  object  perimetry"  (Elliot)  and 
with  the  help  of  "scotometers. "  For  the  various  methods  of  visual 
field  examinations,  consult  pages  81-87. 

Bjerrum's  scotoma  is  topographically  difTerent  from  that  which 
occurs  in  simple  optic-nerve  atrophy,  and  may  be  utilized  as  a  differen- 
tial test  between  the  two  conditions,  as  Bjerrum  has  already  suggested. 
The  scotoma  is  peculiar,  in  that  wherever  situated  it  is  in  direct  continu- 
ity' with  the  blind-spot.     The  scotoma  may  extend  from  the  blind-spot 

and  jiass  in  an  arc  above  and  below  the 
fixation  point  to  end  at  the  nasal  side  of  it. 
about  the  horizontal  meridian,  or  the  de- 
fective area  may  merge  with  the  blind 
area  commonly  existing  in  the  nasal  part 
of  the  field.  Should  the  arcuate  scotoma 
extend  until  its  ends  unite,  an  annular 
scotoma  is  produced.  As  this  scotoma 
(Bjerrum's  scotoma)  always  starts  at  the 
blind-spot  it  must  be  due,  as  Bjerrum  has 
pointed  out,  to  a  limited  destruction  of 
the  nerve  bundles  of  the  papilla  at  the 
margins  or  sides  of  the  excavation. 
Bjerrum's  observations  have  been  abun- 
dantly confirmed  (Me i sling,  Berry, 
Sinclair,  Ronne,  EUiot  and  many  others).  It  constitutes  a  most 
important  sign  of  glaucoma,  even  if  it  is  not  a  pathognomonic  visual 
field  defect.  Naturally,  should  there  be  hniited  destruction  of  nerve 
fibers  in  the  papilla  in  other  diseases,  for  example,  retrobulbar  neuritis, 
neurorctinitis,  etc.,  they  would  be  intorjircted  by  closely  similar 
scotomas.  Bjerrum's  scotoma  may  l)e  ])artially  or  wholly  relative 
and  although  it  usually  arises  from  the  blind-spot  it  may  also  begin  in 
another  part  of  the  arc  (Van  der  Hoeve). 

Honne's  Nasal  Step. — As  Ronne  points  out,  a  small  i)arac('iitral 
arciform  scotoma  is  a  conunon  phenomenon,  and  to  a  l)reak  in  the 
nasal  field,  whereby  an  alteration  takes  place  in  the  boundary  line  of 
the  field  at  the  inner  side  from  vertical  to  horizontal  along  the  hori- 
zontal meridian,  which  it  jjursues  for  a  varj'ing  distance,  before  it 
again  assumes  a  vertical  or  nearly  vertical  direction,  he  has  given 
the  name  "nasal  step."  (Quoting  Elliot,  the  explanation  of  this 
"ste])"  is  as  follows:  H  the  arching  ojjtic  nerNc  fibers  i)roceeding 
to  the  temporal  extremity  of  the  retina  are  e(iually  damaged,  both  at 
the  ui)i)er  and  lower  margin  of  th(>  disc,  the  result  will  be  an  own 
impairment  of  the  nasal  side  of  the  Held;  if  either  the  upper  or  lower 
fibers  are  most   d.-imaged   the  Held  supjjliecl  by   these  libers  will  show 


Fig.  186. — Annular  scotoma  in 
chronic  glaucoma;  moderate  con- 
traction of  the  peripheral  field. 


IRIDESCENT   VISION 


405 


a  corresponding  restriction  and  such  unequality  of  lesion  is  demon- 
strable in  a  careful  chart  of  the  visual  field  and  constitutes  Ronne's 
sign.  Hence  the  step  may  be  either  above  or  below  the  horizontal 
meridian.  It  is  an  important  sign  and  cannot  be  detected  by  ordinary 
perimetry  with  large  test  objects  (Fig.  178). 

SeideVs  sign  consists  in  a  sickle-shaped  extension  of  the  blind  spot 
upwards  or  downwards  or  in  both  directions.  Such  scotomas,  it  is 
said  by  Seidel,  may  be  found  in  the  field  of  an  unaffected  eye,  its  fellow 
being  glaucomatous.  As  the  glaucomatous  process  advances  these 
sickle-shaped  scotomas  may  develop  into  scotomas  of  the  Bjerrum 
type.  Circular  annular  scotomas  have  been  referred  to;  direct  vision 
may  be  blotted  out  by  a  central  scotoma,  and  peripheral  scotomas 
may  be  the  forerunners  of  subsequent  defects  with  peripheral  visual 
field  (Figs.  187,  188).     Not   all   the  scotomas  in   the  visual  field  in 


Fig.  187. — Visual  field  of  right  eye 
in  chronic  glaucoma,  showing  the 
mechanism  of  the  loss  of  the  lower  and 
inner  portion  of  the  field,  preceded  by  a 
scotoma,  which  gradually  extends. 
Scotoma  represented  by  parallel  lines; 
area  of  dull  vision  which  subsequently 
is  completely  lost,  by  dots. 


Fig.  188.— Later  stage  of  Fig.  187. 
The  scotoma  has  extended,  and  the 
area  of  the  visual  field  in  which  sight 
was  only  dulled,  and  which  is  repre- 
sented by  dots  in  the  preceding  figure, 
has  become  completely  dark. 


glaucoma  are  due  to  destruction  of  the  fibers  in  the  nerve-head. 
Some  depend  upon  alterations  in  the  retina  due  to  pressure  or 
to  alterations  in  its  vascular  supply. 

6.  Iridescent  Vision. — This  consists  of  a  definite  ring  surrounding 
artificial  lights,  which  thus  become  invested  with  a  colored  halo  ("halo 
vision").  First  there  is  a  dark  band,  followed  by  a  concentric  zone  of 
prismatic  colors. 

This  phenomenon  has  been  attributed  to  various  causes  depending 
upon  physiologic  or  physical  effects.  Experimental  evidence  tends  to 
support  the  opinion  that  the  cause  resides  in  the  cornea,  and  depends 
on  alterations  in  its  epithelium,  the  result  of  exaggerated  pressure.^ 

1  Halo  vision  occurs  in  mild  attacks  of  iritis  with  slight  deterioration  of  vision. 
It  may  also  be  caused  by  a  laj^er  of  mucus  overspreading  the  cornea  during  chronic 
conjunctivitis.  According  to  Myles  Standish,  the  halo  due  to  mucus  has  only  the 
outer  or  red  and  yellow  bands.  The  presence  of  blue  in  the  halo  may,  therefore, 
he  thinks  be  regarded  as  indicating  increased  intra-ocular  tension. 


406  GLAUCOMA 

Subjective  sensations  of  light  are  experienced  at  times  by  totally 
blind  glaucomatous  patients.  The  explanation  is  probabh'  a  mechani- 
cal one,  and  the  sensation  depends  upon  a  dragging  on  the  retina.  In 
one  case  noted  by  the  writer,  both  eyes  being  blind  from  glaucoma, 
the  patient  declared  "all  things  seemed  to  be  a  sea  of  red  fire." 

The  clinical  varieties  of  glaucoma  may  now  be  described. 

1.  Acute  Glaucoma  {Acute  Congestive  Glaucoma). — This  typ)e 
of  the  disease  is  usually  divided  into  two  stages: 

(a)  Period  of  Incubation,  or  Prodromal  Stage. — This  is  character- 
ized by  sudden  failure  in  the  amplitude  of  accommodation,  with  a 
desire  to  resort  to  stronger  reading-glasses;  temporary  obscurations 
of  vision,  either  dim  vision  or  quite  complete  loss  of  sight, 
lasting  for  many  minutes;  attacks  of  foggy  vision,  due  to  increased 
intra-ocular  tension,  all  things  apparently  being  invested  with  a  haze; 
and  the  phenomena  of  colored  halos  around  artificial  lights.  There 
may  be  some  periorbital  pain,  the  pupil  is  slightly  dilated,  and  the 
cornea  and  the  aqueous  humor  faintly  turbid.  The  appearance  of  the 
optic  nerve  at  this  stage  is  not  characteristic. 

These  prodromes  bear  some  relation  to  emotional  excitement  and 
insomnia,  and  may  occur  when  the  head  is  congested  or  after  a  full 
meal.  After  the  eye  regains  its  natural  state,  in  a  week  or  two  the 
symptoms  may  reappear,  again  to  subside  and  to  be  replaced  by  a 
fresh  exacerbation  or  a  true  "glaucomatous  attack."  The  early 
period  of  glaucoma  may  last  one  or  more  years. 

(6)  Period  of  Attack,  or  the  "Glaucomatous  Attack." — This  com- 
monly begins  during  the  latter  part  of  the  night,  sometimes  preceded 
by  prodromes,  but  sometimes  without  previous  warning,  and  is  char- 
acterized by  violent  pain  in  the  head,  so  severe  that  it  may  induce 
nausea  and  vomiting.  The  face  may  be  pallid,  the  extremities  cold,  or 
there  may  be  flushing  and  general  fever.  The  eyelids  are  swollen,  the 
conjunctiva  injected  and  sometimes  chemotic,  the  cornea  steamy  and 
anesthetic,  the  pupil  scmidilated  and  motionless,  the  aqueous  turbid, 
and  the  iris  discolored.  The  tension  rises  very  high,  tlie  tonometer 
registering  80  mm.  of  Hg  and  higher,  and  vision  is  rapidly  lost,  often 
only  light-perception  remaining,  and  even  this  may  be  abolished. 
Sometimes  the  attack  is  bilateral,  or  only  a  few  hours  elapse  before 
the  second  eye  is  affected.  Again,  the  interval  between  the  two 
attacks  maj^  last  weeks,  months,  or  even  years. 

Gradually  the  synij)toms  pass  away,  with  the  exception  of  slight 
impairment  in  the  mobility  of  the  iris,  some  limitation  of  the  field,  and 
a  little  rise  in  tension.  Blindness  almost  never  occurs  in  the  first  onset. 
At  this  time  characteristic  c)plithalm()scoi)ic  appearances  are  not 
present.  After  a  numb(M-  of  attacks,  examination  of  the  eye-ground 
during  a  remission  (the  fundus  is  not  visible  tluring  an  attack)  may 
reveal  the  characteristic  cupping,  the  halo,  and  the  arterial  pulse. 

If  the  disease  in  unchecked,  the  eye  passes  into  a  (jlaucomdtous  state, 
with  I'lKo.d  and  dilated  pupil,  discolored  iris,  greenish  rell(>x  from  the 
lens,  vitreous  opacities,  shallow  anterior  (liamber,  and  Iimzv  cornea. 


SUBACUTE    OR   CHRONIC    CONGESTIVE    GLAUCOMA  407 

Vision  is  now  gradually  destroyed  and  the  eye  reaches  the  state  of 
absolute  glaucoma;  the  ball  is  stony  hard,  the  iris  atrophic,  the  lens 
cataractous  and  pushed  forward,  the  anterior  chamber  obliterated, 
the  sclera  discolored,  the  episcleral  vessels  coarsely  injected,  the  cornea 
opaque,  or  perhaps  ulcerated.  Finally,  there  is  disorganization  of  all 
the  structures  of  the  eyeball,  and  the  sclera  gives  way  with  the  forma- 
tion of  staphylomas,  or  the  eyeball  slowly  atrophies  as  the  result  of 
choroiditis,  change  in  the  vitreous,  and  detachment  of  the  retina. 
Unchecked  acute  glaucoma,  instead  of  pursuing  this  course,  occa- 
sionally passes  into  a  chronic  congestive  type.^ 

Spontaneous  rupture  of  a  glaucomatous  eyeball  occasionally  occurs; 
at  the  same  time  there  may  be  choroidal  hemorrhage. 

Glaucoma  fulminans  is  the  name  applied  to  an  aggravated,  rare 
form  of  the  acute  disease,  in  which  the  symptoms  may  be  fully  devel- 
oped in  a  few  hours  without  a  prodromal  stage.  There  is  no  remis- 
sion, and  the  destruction  of  vision  is  swift  and  permanent. 

2.  Subacute  or  Chronic  Congestive  Glaucoma. — This  type 
may  or  may  not  begin  with  the  early  signs  already  described,  or  may 
be  the  sequel  of  repeated  acute  attacks.  The  eye  gradually  passes 
into  a  stage  characterized  by  the  constant  presence  of  a  series  of  symp- 
toms which  are  often  described  under  the  title  chronic  congestive 
glaucoma. 

The  cornea  is  deficient  in  transparency  or  positively  steamy;  there 
are  marked  tortuosity  of  the  episcleral  veins  and  some  discoloration 
of  the  scleral  tissue;  the  aqueous  humor  is  turbid  and  the  deeper  media 
present  opacities;  ophthalmoscopic  examination,  when  it  is  possible, 
reveals  the  cupped  disk  and  pulsating  vessels;  the  tension  of  the  eye  is 
raised;  the  pupil  is  semidilated,  and  the  iris  sometimes  atrophic  and 
sometimes  not.  Hence  two  types  of  chronic  congestive  glaucoma  are 
described,  one  associated  with  degenerative  changes  in  the  iris  and  one 
without  such  association. 

The  field  of  vision  is  either  contracted  upon  the  nasal  side  or  a  quad- 
rant of  the  field  is  darkened,  or  the  other  defects  described  on  pages 
402-405  may  be  discovered. 

During  the  course  of  the  disease  acute  or  subacute  attacks  super- 
vene; that  is,  there  are  sharp  ciliary  pain,  increased  steaminess  of  the 
cornea,  increased  injection  of  the  eyeball,  sinking  of  the  vision,  exag- 
geration of  the  tension,  and  marked  anesthesia  of  the  cornea.  The 
attack  gradually  subsides,  but  in  a  few  days  or  weeks  repeats  itself. 
Sometimes  instead  of  a  subacute  attack  of  this  character,  an  acute  con- 
gestive exacerbation  occurs,  in  all  respects  resembling  the  acute  form 
of  the  disease  just  described,  and  like  it  ending  in  absolute  glaucoma 
or  in  degeneration  of  the  tissues  of  the  eye.  This  disease  may  last 
from  several  months  to  a  year. 

^Elliot  objects,  with  justice,  to  the  terms  "prodromal  stage"  and  "absolute 
glaucoma,"  but  they  are  in  such  common  use  that  the  author  has  continued 
them  in  the  text.  Elliot's  classification  is:  early  glaucoma,  established  glaucoma, 
late  glaucoma. 


408  GLAUCOMA 

3.  Chronic  Glaucoma  or  Non=congestive  Glaucoma  (Usually 
Known  as  Simple  Chronic  (rlauconia  or  Glaucoma  Simplex). — This  typo 
of  the  disease  is  characterized  by  an  absence  of  the  signs  of  ghiuconia  in 
the  anterior  aspect  of  the  eye,  at  least  on  ordinary  inspection.  By 
careful  examination  (loupe  or  corneal  microscope),  slight  steaminess 
of  the  cornea  may  sometimes  be  detected,  with  a  little  lack  of  transpar- 
ency in  the  aqueous  humor.  So,  too,  there  may  be  some  undue  tortu- 
osity of  the  perforating  branches  of  the  episcleral  plexus.  In  general 
terms,  however,  there  is  an  absence  of  congestive  symptoms  and  there 
is  no  pain.  The  tension  of  the  eyeball  is  always  increa.^ed  at  some 
period  of  the  disease,  but  this  s^'mptom  is  not  constantly  present,  or  it 
may  be  present  at  one  portion  of  the  day  and  not  at  another,  or  during 
the  night  and  not  in  the  day  time.  As  observations  with  the  tonometer 
indicate  that  increased  tension  is  almost  always  present,  although  its 
degree  may  be  a  minor  one,  the  necessity  of  frequent  tononietric  tests 
at  different  times  during  twentj'-four-hour  periods  is  evident.  The 
depth  of  the  anterior  chamber  is  not  materially  altered..  If  in  the 
affected  e\'e  corneal  involvement  is  made  evident  by  nebulous  vision, 
halos,  etc.,  or,  in  other  words,  by  irritative  attacks,  the  case  ceases  to  be 
one  of  simple  glaucoma,  and  should  be  grouped  with  the  chronic  con- 
gestive types. 

Usually  both  eyes  are  affected  simultaneously  or  successively;  but 
it  is  difficult  to  fix  the  exact  date  of  the  onset  of  this  variety  of  glau- 
coma, because  of  the  absence  of  the  pronounced  early  symptoms  which 
precede  the  other  types  of  this  disease. 

If  both  eyes  are  affected,  the  one  is  usually  more  advanced  than  the 
other,  and  the  pupil  is  generally  slightly  larger  on  the  side  of  the  greater 
disease.  In  the  later  stages  a  greenish  sheen  from  the  i)upil  is  often  dis- 
tinct. The  central  vision  may  be  good,  and  in  the  earlier  stages  of  the 
disease,  after  the  correction  of  any  refractive  error,  may  reach  the  nor- 
mal standard  and  this  may  be  true,  even  when  the  disease  has  lasted  a 
long  period  of  time  and  marked  contraction  of  the  field  is  present. 

The  media  are  practi(^ally  clear,  and  the  disoa,se  is  det(>ct(>d  with 
the  oplitlialmoscope  by  oljserving  the  characteristic  cup  in  the  nerve- 
head,  the  halo  surrounding  it,  and  ready  development  of  an  arterial 
pulse  by  slight  pressure.  The  field  of  vision  gives  important  informa- 
tion, and  it  assumes  one  or  otiier  of  the  characteristics  described  on 
page  402  (see  Figs.  178-188).  The  cenlial  color  percejition  is  gtxnl. 
and  the  contraction  of  the  ijeiiphcral  color  j)erc('ptioii  usuall}' 
corresponds  with  that  of  the  field  for  white. 

Simple  chronic  glaucoma  may  l>e  transformed  into  subacute  or  acute 
glaucoma,  but  often  continues  throughout  its  course  without  aggres- 
sive symj)toms,  retaining  the  characters  and  visual  field  characteristics 
which  have  been  described.  Opiic-ncrrc  atrophi/  with  txcaralion.  or 
so-called  (ihutcoina  simplex  without  rise  of  tension  should  be  distin- 
guished froiM  chronic  non-congest  ive  glaucom;i  becaus(>  the  tension  does 
not  rise  above  the  iioiiual  limits  (20  28  mm.  |.Morax|),  the  visual  field 
])lieii()iiicii.i  liilTrr  I  roiii  t  hose  of  1 1  iie  liiaiicoiiia  (  p.-i^es  U)'2    10."))  and  I  here 


1 


CHRONIC    GLAUCOMA    OR    NON-CONGESTR'E    GLAUCOMA         409 

is  no  favorable  response  to  miotics  or  operation.  Alorax  believes  the 
processes  is  due  to  a  special  affection,  localized  in  the  blood-vessels  or 
optic  fibers,  whose  characteristics  are  a  slowly  developing  double  atro- 
phy with  excavation.  H.  S.  Gradle  is  satisfied,  as  the  result  of  his 
observations,  that  this  condition  represents  a  disease  sui  generis  of 
unknown  origin,  possibly  due  to  a  systemic  selective  toxin  which  at- 
tacks the  optic  nerves. 

Causes. — (a)  Predisposing  Causes. — Primarj'  glaucoma  is  rare  be- 
fore the  fortieth  year;  not  1  per  cent.,  according  to  Priestley  Smith,  be- 
gins earHer  than  the  twentieth  year.^  Glaucoma,  generally  unilateral, 
ma}'  occur  in  children,  and  juvenile  glaucoma  usuall}'  begins  between 
the  ages  of  fifteen  and  twenty;  its  prodromal  period  is  of  long  duration, 
the  dominant  refraction  is  myopic.  There  may  be  a  hereditary  tendency 
to  glaucoma,  and,  according  to  Nettleship,  if  the  disease  appears  in  more 
than  one  generation,  it  develops  at  an  earlier  age  than  in  the  preceding 
generation  ("anticipation").  Lawford's  research  shows  that /a/^nZta? 
glaucoma  is  continuous  in  descent  and  is  transmitted  by  both  sexes. 
Jews,  Egyptians,  and  Brazilian  negroes  are  said  to  be  peculiarly  liable  to 
the  disease.  The  glaucomatous  eye  is  usualh^  hyperopic,  although 
Priestley  Smith's  statistics  do  not  indicate  a  striking  preponderance 
of  this  refractive  state.  Myopia  confers  no  immunit\'  against  glaucoma. 
There  is  a  relation  between  smallness  of  the  cornea  and  glaucoma. 
The  average  horizontal  diameter  of  the  normal  cornea  is  11.6  mm.; 
of  the  glaucomatous  cornea,  11.1  mm.  (P.  Smith).  A  large  lens  is  a 
predisposing  factor,  and  small  ej'es,  in  which  the  lens  may  be  dispro- 
portionately large,  are  more  liable  to  the  disease  than  normal  globes. 

(h)  Exciting  Causes. — Glaucoma  may  be  excited  in  ej'es  predisposed 
to  the  disease  by  worry,  insomnia,  bronchitis,  cardiac  disease,  syphilis, 
gout,  influenza,  angioneurotic  edema  and  neuralgia  of  the  fifth  nerve. 

In  general  terms  it  may  be  said  glaucoma  comparatively  rarely 
occurs  in  persons  in  perfect  health  as  examinations  according  to  modern 
methods  readily  demonstrate.  A.  Knapp  classifies  cases  of  j^rimary 
glaucoma  into  those  which  are  "circulatory"  and  those  which  are 
"nervous."  The  first  group  includes  cases  which  are  characterized 
by  congestive  attacks  and  by  retinal,  vascular  and  local  conditions  which 
favor  increased  tension.  The  second  group  includes  cases  characterized 
by  dysglandular  disturbances  which  affect  any  type  of  eye. 

Sometimes  glaucoma  follows  injury  and  hemorrhage  into  the  uveal 
tract,  and  traumatic  glaucoma  may  be  caused  bj'  a  contusion  of  the 
globe  without  rupture  of  its  coats. 

It  has  been  stated  that  at  corresponding  ages  usually  there  is  higher 
average  blood-pressure  in  glaucomatous  subjects  than  in  non-glau- 
comatous  subjects,  and  that  arteriosclerosis  and,  therefore,  increased 

^  Priestley  Smith's  statement  is  as  follows :  The  frequency  of  glaucoma  increases 
"slowly  at  first,  more  rapidly  later  in  each  decade,  until  about  the  sixtieth  year. 
Between  sixty  and  seventy  it  is  about  as  frequent  as  between  fifty  and  sixty.  After 
seventy  its  frequency  diminishes."  (quoted  by  Elliot).  These  results  have  been 
confirmed  by  other  more  recent  obser\'ers. 


410  GLAUCOMA 

blood-pressure  are  exciting  causes  of  glaucoma.  This  contention  is  dis- 
puted by  many  observers,  for  example,  H.  Sattler,  Freeland  Fergus,  H. 
C.  Craggs,  and  C.  G.  Taylor  and  Elliot  maintains  that  high  blood- 
pressure  is  not  a  factor  in  the  causation  of  glaucoma.  Disturbances 
in  the  organs  of  internal  secretion  have  been  suggested  bj'  E.  von  Hippel 
as  a  possible  cause  of  glaucoma. 

Overuse  of  ametropic  or  improperly  corrected  eyes,  by  causing  uveal 
congestion,  maj^  bring  on  glaucoma  in  an  eye  predisposed  to  the  dis- 
order. The  influence  of  strain  upon  the  accommodation  was  explained 
by  Snellen  as  follows:  In  the  young  eye,  during  accommodation  for  a 
near  point,  the  diameter  of  the  lens  is  reduced  to  about  the  same  extent 
as  that  of  the  contracting  ciliar}'  muscle.  The  circumlental  space  re- 
mains about  as  wide  as  it  was  before,  and  the  zonula  remains  tense  as 
before.  But  the  conditions  are  quite  different  in  advanced  hfe,  when 
the  elasticity  of  the  lens  is  lost;  the  cihary  muscle  contracts,  but  the 
form  and  size  of  the  lens  remain  unchanged.  The  cihary  process  is 
thereby  pressed  against  the  lens  and  the  zonula  slackened;  hence  the 
necessity  of  correction  of  refractive  errors  as  a  preventive  measure. 
On  the  other  hand  Gronholm,  believing  that  the  filtration  channels  are 
widened  in  the  act  of  accommodation  and  by  contraction  of  the  pupil,, 
suggested  that  glaucoma  patients  should  be  advised  to  stay  as  much 
as  possible  in  a  bright  light,  and  to  read  so  long  as  they  have  accommo- 
dation power  and  their  pupils  contract  to  light.  Arthur  Thomson 
recommends  that  in  glaucomatous  subjects  the  action  of  the  ciliary 
muscle  should  be  restored  by  suitable  exercises  (quoted  from  Elliot). 

In  a  number  of  instances  instillation  of  mydriatics  has  caused 
glaucoma.  Acute  glaucoma  appears  to  be  more  frequent  in  winter 
than  at  other  seasons  of  the  year  (Geisler) . 

Should  a  patient  between  his  fiftieth  and  sixtieth  year  desire  to 
change  his  reading-glass  frequently,  or  to  use  one  stronger  than  is  suited 
to  his  age  or  the  condition  of  the  refraction  of  his  eye,  there  is  reason  to 
apprehend  the  onset  of  glaucoma.  On  the  whole,  the  disease  is  slightly 
more  common  in  women  than  in  men.  Those  symptoms  which  have 
been  doscri]:)od  as  prodromes  are  distinctive  in  themselves,  and  ac(iuire 
an  iini)ortance  greater  than  any  probable  predisposition. 

Pathogenesis  and  Pathology.—  Three  kinds  of  fluid  are  recog- 
nized, within  the  eyeball:  tho  blood  within  the  blood-vessels,  the 
lymph  within  tho  perivascular  lymiih-chaimcls  and  the  spaces  in 
the  uveal  tract,  and  the  intra-ocular  fluid  whii-h  is  concerned  with  the 
nourishment  of  the  vitreous  and  lens,  supplies  the  aqueous  chamber, 
and  whieh,  as  was  proved  by  Leber,  proceeds  from  the  epithelium  of  the 
ciliary  body.  It  is  probable  tliat  the  lymph  formation  of  the  (\ve  is 
pr()(hi(HMl  in  tiie  eiliary  body  Ijy  a  jjrocess  of  transudation,  and  not  as 
has  been  taught,  by  a  process  of  secretion. 

The  chief  stream  of  the  intra-ocular  fluid  thus  derived  proceeds  over 
the  lens  and  through  tlu^  pupil  into  the  anterior  chamber,  traverses  the 
latter  to  niach  tiie  angle  foiined  by  the  junction  of  the  iris  and  I'ornea, 
passes  through  the  meshes  of  the  ligamentum  pectinatuin,  and  by  dilTu- 


CHRONIC    GLAUCOMA    OR   NON-CONGESTIVE    GLAUCOMA 


411 


sion  and  filtration  is  taken  up  by  Schlemm's  canal.  From  this  canal 
the  greater  quantity  of  the  fluid  passes  into  the  anterior  ciliary  veins, 
a  part  of  it. being  absorbed  and  eliminated  by  the  iris  (Nuel,  Benoit). 
Arthur  Thomson  concludes  from  his  resarches  that  escape  of  fluid  from 
.  the  anterior  chamber  into  Schlemm's  canal  and  from  there  into  the 
veins  is  the  result  of  a  "pumping  action"  whereby  the  muscles  of  the 
ciliary  body  and  of  the  iris  draw  back  the  scleral  process  and  so  open 
the  spaces  in  the  pectinate  ligament.  Only  a  very  small  portion  of  the 
fluid  flows  backward  through  the  vitreous  and  escapes  by  way  of  the 


Fig.  189. — Photomicrograph  of  a  specimen  prepared  by  Dr.  Brown  Pusey. 
tion  between  Schlemm's  canal  (a)  and  scleral  vein  (5). 


Communica- 


perivascular  lymph-channels  in  the  optic  nerve.  According  to  Priest- 
ley Smith,  it  is  doubtful  if  there  is  any  continuous  stream  from  the 
vitreous  into  the  aqueous  chamber,  but  the  anterior  hyaloid  membrane 
and  suspensory  ligament  are  easilj'-  permeated  bj^  it,  and  in  health  any 
excess  of  fluid  in  the  vitreous  chamber  escapes  by  the  filtration  angle 
in  the  manner  already  described.  The  pressure  of  the  fluid  regulates 
the  outflow,  so  that  when  the  afflux  is  increased  a  compensating  in- 
crease of  the  efflux  occurs. 

The  fluids  of  the  aqueous  and  vitreous  chambers  are  nearly  identical 
in  composition  and  contain  about  95  per  cent,  of  water,  1  per  cent,  of 
extractives  and  salts,  and  a  minute  quantity  of  albumin.  The  intra- 
ocular pressure,  which  is  equivalent  to  that  of  a  column  of  mercury 


412 


GLAUCOMA 


25  mm.  in  height,  is  the  same  in  the  vitreous  and  the  aqueous  chambers, 
and  preserves  the  shape  and  tension  of  the  eyeball.^  If  anything  oc- 
curs to  disturb  its  regulation,  to  quote  Priestley  Smith,  "the  pressure 
in  the  ocular  chambers  rises  above  the  physiologic  limits  and  we  have 
the  complex  disturbance  of  function  and  structure  called  glaucoma." 

What  exactly  are  the  factors  potent  in  disturl)ing  the  regulation  of 
pressure  has  never  been  entirelj^  determined,  and  numerous  theories 
have  been  advanced. 

The  theory  which  has  been  and  is  still  widely  maintained  is  that 
one  which  assumes  a  diminution  in  the  outflow  and,  therefore,  a  reten- 
tion of  fluid  (retention  theory).     It  obtained  proper  recognition   when 


■''-■■■ '-.Vvj,-  , 


ti'-vi  ^y-'-  "■'■'"*  ■:-^•7^v^ 


\ 


Fig.   190. — Annie  of  the  interior  chamber  of  a  normal  eye:  c,  Corneo;  s,  sclera:  o-  'r'*: 
c.h,  ciliary  body;  Lp,  ligamentum  pectinatum;  s.c,  Schlemm's   caual. 

Knies  and  Weber  demonstrated  that  in  glaucomatous  eyes,  with  shallow 
antc^rior  chambers,  there  is  an  adhesion  of  the  iris  base  to  the  peripiierv 
of.the  cornea,  which  prevents  filtration  at  the  angle  of  the  anterior 
chamber  and  causes  retention  of  the  intra-ocular  fluiii  (Fig^^-  1-^0 
and  191).  This  adhesion  Knies  regarded  as  an  inflanunatory  process 
■ — that  is,  as  a  species  of  anterior  iridocyclitis,  while  Welder  considered 
it  to  be  secondary  to  the  pressure  induced  by  an  al)norinall\'  swollen 
ciliary  ])ody.  Tiic  fact  that  a  mydriatic  docs  harm  to  an  <>yc  predis- 
posed to  glaucoma  by  dilating  the  pupil,  rolling  l)ack  the  iris,  and  partly 
closing  the  filtration  angle,  and  that  eserin  does  good  by  contracting  the 
pupil  and  drawing  away  the  iris  from  this  angle,  indicates,   that  the 

'  Klliot  coiiHJdcrs  it  iinijortant  to  i)<)iiil  out  that  thi-  prcssun*  of  the  luiucoiis 
and  vitreous  chainber.s  is  not  exMclly  the  same  ihrounliout.  'I'here  are.  aoeoniing 
to  him,  "distinct  Ihoun'i  wlighl  dilTerencc  of  pressun*  at  variouH  points  in  the  mass 
of  lluid  within  I  he  eye." 


CHRONIC    GLAUCOMA    OR    NON-CONGESTIVE    GLAUCOMA 


413 


explanation  of  glaucoma  is  to  be  found  not  in  an  increase  of  secretion, 
but  in  a  disturbance  of  excretion. 

Mydriatic  glaucoma  has  also  been  ascribed  to  narrowing  or  closure 
of  the  iris  crypts,  an  explanation  which  Priestley  Smith  declines  to 
accept,  for  if  it  were  correct,  mydriasis  should  always  be  followed  by 
rise  of  tension. 

According  to  Priestley  Smith,  obstruction  of  the  circumlental  space 
— i.e.,  the  space  between  the  margin  of  the  lens  and  the  surrounding 
structures — and  consequent  rise  of  pressure  may  follow  increased  size 
of  the  lens  due  to  advancing  years,  unusual  smallness  of  the  ciliary 
area  in  hyperopia,  or  abnormal  enlargement  of  the  ciliary  processes, 


^'^S^i::^--.. 


;  -v;  v-.'/:>i-"'»r;*^iiii 


■'^s^i 


<■/■. 


Fig.  191. — Angle  of  the  anterior  chamber  in  long-standing  absolute  glaucoma:  c, 
Cornea;  s,  sclera;  j,  iris;  c.b,  ciliary  bodj^  a.c,  angle  of  chamber  closed  by  adhesive 
inflammation  of  the  iris  base  to  periphery  of  cornea,  obliterating  filtration  area. 

and  vascular  disturbance  which  congests  the  uveal  tract.  It  is  possible 
that  hypersecretion  is  sometimes  concerned  in  the  onset  of  glaucoma, 
and  that  serosity  of  the  fluids  plays  a  role  in  those  forms  which  present 
a  deep  anterior  chamber  and  wide  filtration  angle;  but  obstruction  at 
this  angle  is  part  of  the  glaucomatous  attack  in  the  vast  majority  of 
cases. 

C.  Hess  points  out  that  bulbous  outgrowths  may  develop  on  the 
summits  of  the  ciliary  processes  in  the  course  of  life.  He  has  observed 
swelling  of  these  processes,  followed  by  narrowing  of  the  circum- 
lental space  in  two  eyes  with  severe  primary  glaucoma  with  the  aid 
of  a  specially  constructed  lamp.  Individual  differences  of  the  ciliary 
body  are  as  important  as  differences  in  the  size  of  the  lens,  and  may 
have  a  distinct  bearing  on  closure  of  the  angle  of  the  anterior  chamber 
and  the  production  of  glaucoma. 

Laqueur  and  other  observers  have  maintained  that  glaucoma  de- 
pends upon  obstruction  of  the  intra-ocular  lymphatics,  which  find  their 


414  GLAUCOMA 

way  out  with  the  venae  vorticosae,  owing  to  rigidity  of  the  sclerotic  coat. 
Brailey  described  a  chronic  inflammation  of  the  cihary  processes  and 
iris  periphery,  with  distention  of  the  vessels,  as  the  earliest  lesion  in 
glaucoma.  Stilling  taught  that  a  hardening  of  the  sclera  surround- 
ing the  papilla,  through  which  waste  fluid  escapes,  leads  to  glaucoma, 
and  Strokousky  attributes  glaucoma  to  an  indurative  scleritis. 

Evidently  all  retention  theories  assume  that  the  cause  of  glaucoma 
depends  upon  an  obstruction  to  the  outflow  of  liquids  from  the  eye 
occasioned  by  an  interference  with  their  escape  through  Fontana's 
spaces  at  the  filtration  angle,  or  through  the  perivascular  lymph- 
channels  in  the  posterior  part  of  the  eye,  or  through  both  of  these  exits; 
hence  the  fluid  accumulates,  the  intra-ocular  tension  rises,  and  glau- 
coma results.  In  other  words,  upon  the  increased  tension  depend 
all  the  disturbances  in  the  eye  in  this  disease. 

But  this  explanation  is  not  satisfactorj'  to  many  observers,  and 
certain  objections  have  been  advanced.  For  example,  it  is  main- 
tained that  although  adhesion  of  the  root  of  the  iris  and  blocking  of 
Fontana's  spaces  are  usually  present  in  congestive  glaucoma,  it  does 
not  follow  that  this  condition  is  the  cause  of  the  glaucomatous  process; 
it  may  as  well  be,  indeed,  it  is  more  likely  to  be,  a  result  of  it.  More- 
over, while  it  is  practically  always  present  in  the  eyes  with  long-stand- 
ing glaucoma,  it  may  be  absent  in  an  early  stage  of  the  disease.  But 
especially  is  it  true  that  this  theory  does  not  satisfactorih-  explain  the 
mechanism  of  so-called  simple  glaucoma,  in  which  increased  tension 
does  necessarily  not  play  a  conspicuous  role. 

Wahlfors  believes  that  the  search  for  the  cause  of  simple  glaucoma 
must  be  made  in  the  choroid,  and  maintains  that  the  primary  lesion  is 
an  atrophic  process  in  the  choriocapillaris,  leading  to  nutritional  dis- 
turbances in  the  layer  of  the  rods  and  cones,  whereby  the  important 
symptoms  of  this  variety  of  the  disease,  diminution  of  light-sense, 
defects  in  the  field  of  vision,  and  excavation  of  the  nerve-head  (see 
page  398),  can  be  explained.  He  explains  glaucomatous  increase  of 
tension  by  assuming  tiiat  ])aralysis  of  the  muscular  network  of  the 
choroid  causes  a  slowing  of  the  intra-ocular  liquids,  tliat  the  retarded 
flow  permits  the  deposition  of  formed  elements  in  the  channels  of  exit, 
and  that,  therefore,  there  is  a  retention  of  the  liquid;  finally,  the  venae 
vorticosffi  are  compressed  by  reason  of  the  increased  tension,  and 
V(!ii(>us  stasis  is  the  result.  According  to  the  manner  and  activity  with 
whi(;li  tiiese  factors  iniluencc  the  eye,  the  various  types  of  glaucoma  are 
produced. 

Kiiics  and  other  writers,  unable  to  re(H)nci!e  any  of  the  tlu'ories  of 
glaucoma  \vi(  h  I  he  so-called  sini])l('  variety  of  t  ho  disease,  ineliniHl  to  sepa- 
rate it  from  the  glaucoma  class  antl  i)la('e  it  among  diseases  of  the  optic 
nerve.  In  the  present  .state  of  our  knowledge,  and  keeping  clearly  in 
view  the  presence  of  increased  tension,  this  does  not  seem  advisable. 
Ind(>etl,  as  Pri(!stlev  Smith  forcefully  i)uts  it,  tiie  nature  of  ciironic 
and  acut(!  glaucoma  is  not  essentially  dilTerent,  in  that  th(>re  is  a  close, 
thou^^li  liiiMen,  resembhuice.     "In  Ixtlh  we  liiid  (he  )ire<liIec(ion  for 


CHRONIC    GLAUCOMA    OR    NON-CONGESTR^E    GLAUCOMA         415 

small  eyes;  in  both  there  is  obstructive  displacement  of  the  iris — slowly 
estabhshed  in  the  one  case,  rapidly  in  the  other."  Some  authors 
explain  this  form  of  glaucoma  by  assuming  a  neuritis  which  blocks  the 
lymph-channels  in  the  optic  nerve  and  its  sheath,  and  which  prevents 
the  removal  of  effete  matters  which  normally,  to  slight  degree,  occurs 
through  these  pathways,  and  thus  causes  increased  tension  and  excava- 
tion. Hence  the  disease  is  sometimes  called  posterior  glaucoma,  to 
distinguish  it  from  the  other  variety,  anterior  glaucoma.^ 

Priestley  Smith  beheves  that  "typical  chronic  glaucoma  depends 
on  slowly  increasing  contact  of  the  iris  with  the  cribriform  hgament, 
arising  through  enlargement  or  advance  of  the  lens,  and  involving  in  its 
early  stages  no  serious  compression  of  the  iris." 

W.  Zimmerman  considers  that  the  primarj^  cause  of  glaucoma  de- 
pends upon  a  difference  between  the  general  blood-pressure  and  that  of 
the  eye.  Parsons'  experiments  indicate  that  intra-ocular  tension  may 
passively  respond  to  variations  in  the  general  blood-pressure,  probably 
due  to  alterations  in  the  volume  of  the  intra-ocular  blood-vessels,  but  it 
is  uncertain  that  such  passive  changes  are  sufficient  to  account  for  glau- 
comatous attacks  when  these  are  apparently  produced  b}'  excitement 
or  emotion  (see  page  409). 

The  notable  increase  of  the  amount  of  albumin  which  Uribe  Tron- 
coso  has  found  in  the  aqueous  humor  of  glaucomatous  e3'es  induces  him 
to  advance  the  theory  that  the  symptoms  which  characterize  glaucoma 
are  best  explained  by  its  presence.  The  lesions  in  the  blood-vessels 
which  are  found  in  glaucoma  permit  the  passage  of  the  albumin  from 
the  blood,  and  pathologic  variations  in  the  vitreous  have  also  an  impor- 
tant bearing  on  the  glaucomatous  process.  Leber,  however,  who 
has  reviewed  Troncoso's  work,  was  unable  to  persuade  himself  that 
this  author's  views  are  correct.  A.  Knapp  found  in  an  eye  with 
primar}^  glaucoma  an  albuminous  exudation  which,  by  obUterating  the 
anterior  chamber  through  distention  of  the  posterior  chamber,  pro- 
duced the  increased  intra-ocular  tension. 

Brown  Pusey,  experimenting  with  the  increase  and  decrease  of 
intra-ocular  tension  which  may  be  induced  by  varying  osmotic  pres- 

^  Based  on  the  assumption  that  the  obstruction  to  the  outflow  of  lymph  from 
the  globe  may  be  more  marked  either  in  the  anterior  or  posterior  lymph  system, 
W.  R.  Parker  has  classified  glaucoma  simplex  clinically — as  simple  anterior  glau- 
coma and  simple  posterior  glaucoma.  If  the  anterior  spaces  are  blocked  and  the 
-posterior  spaces  patulous  the  lymph  flow  will  be  backward  and  the  anterior 
chamber  may  remain  normal  in  depth  or  be  but  shghtlj^  shallow.  On  the  other 
hand  if  the  posterior  spaces  are  blocked  and  the  flow  of  lymph  is  forward  the 
lens  and  iris  will  follow  the  flow  and  the  anterior  chamber  will  be  shallow.  If 
the  anterior  spaces  are  free  an  iridectomy  will  be  of  no  avail,  while  if  they  are 
blocked  a  properly  performed  iridectomy  may  restore  a  suflScient  opening  to  relieve 
the  hypertension.  The  clinical  differentiation  between  the  two  forms  of  glaucoma 
simplex  suggested  is  made  by  observing  the  depth  of  the  anterior  chamber.  In  cases 
of  simple  posterior  glaucoma  an  iridectomy  is  performed  while  in  the  cases  of  simple 
anterior  glaucoma  a  trephine  or  other  operation  which  has  for  its  object  the  estab- 
Ushment  of  a  permanent  cicatrix  is  indicated.  See  American  Journal  of  Ophthal- 
mologj',  Vol.  1.,  No.  9,  1918. 


416  GLAUCOMA 

surcs,  believes  that  on  .them  depends  the  explanation  of  the  primary 
cause  of  glaucoma.  M.  H.  Fischer  holds  that  glaucoma  is  due  to  an 
edema  of  the  eyeball,  the  amount  of  water  contained  in  the  hydro- 
phylic  colloids  (chiefly  the  proteins)  being  increased  by  an  augmenta- 
tion of  the  quantity  of  acid  present  in  the  organ.  The  ordinary  exciting 
causes  of  glaucoma  are  responsible  for  this  abnormal  jjroduction  or 
accumulation  of  acid. 

According  to  Thomas  Henderson,  the  underlying  predisposing  and 
causal  factor  of  glaucoma  resides  in  a  primary  obstruction  and  closure 
of  the  pectinate  ligament,  or,  as  he  prefers  to  call  it,  the  cribriform 
ligament.  This  occlusion  is  the  result  of  a  sclerosis  of  the  fibrous 
structure  composing  that  filtration  area  which  results,  first,  in  a  dimi- 
nution, and,  finally,  in  a  complete  obstruction  of  the  outflow  through 
it,  leaving  the  iris,  with  its  crypts,  as  the  only  efferent  channel  for  the 
lymph-streams.  While  in  his  opinion  this  sclerosis  is  the  fundamental 
cause  in  all  cases  of  glaucoma,  he  admits  a  second  and  variable  agent, 
vasomotor  in  nature,  which  determines  the  acute  attacks  of  increased 
intra-ocular  tension.  Henderson's  theory  does  not  seem  to  Priestley 
Smith  to  be  sufficient.  Lovinsohn,  finding  a  striking  deposit  of  pig- 
ment cells,  derived  from  the  cells  lining  the  ciliary  processes,  in  an  eye 
with  absolute  glaucoma,  suggests  that  this  may  be  an  important  factor 
in  the  production  of  acute  glaucoma.  Kiischel  believes  that  loss  or 
disturbance  of  the  elasticitj^  of  the  supporting  tissues  of  the  eyeball  is 
the  cause  of  the  various  tj'pes  of  i)rimary  glaucoma.  In  all  senile 
ej'es  this  produces  the  "glaucomatous  disposition." 

Evidently  all  cases  of  glaucoma  cannot  be  explained  by  any  one 
theory,  and  the  various  clinical  manifestations  of  the  disease,  as  well  as 
the  results  of  treatment,  indicate  that  sometimes  one  factor  and  some- 
times another  is  the  more  potent  in  its  activities.  Of  tho.^e  which 
have  been  described,  obstruction  of  the  circumlental  space  dependent 
upon  increasing  size  of  the  lens  due  to  advancing  years,  oi)structive 
displacement  of  the  iris  slowly  or  rapidly  estal)lished  (Priestl(\v  Smith), 
checking  the  outflow  of  fluid  from  the  interior,  swelling  of  the  ciliary 
processes  closing  the  filtration  angle,  alteration  in  the  composition  of 
the  intra-ocular  fluid  or  its  increase  in  abnormal  conditions  of  the 
vascular  system,  blockinsr  of  the  efferent  channels  by  edema  and  exuda- 
tion, sclerosis  or  pigment  deposition,  and  vascular  or  vasomotor  changes 
furnish  the  most  satisfactory  explanations  of  tiie  v;irious  phases  of 
glaucoma. 

The  pathogenesis  of  secondary  glaucoma  is  eju^ily  understood,  as  the 
(;f)n(litions  which  give  rise  to  it  (see  page  424),  readily  ol)struct  the 
outflow  of  the  iiitiaocular  fluid  and  occasion  its  retention.  MoretJver. 
in  some  varieties  of  secondary  glaucoma  (uveitis),  in  addition  to  the 
accumulation  of  inflanunatory  cells  in  l"oiitan;i's  spaces,  there  is  an 
excess  of  secretion,  liighly  charged  with  alltumin,  troin  the  inflamed 
ciliary  body.  In  brief,  secondary  glaucoma  is  caused  eitlier  by  obstruc- 
tion of  the  filtration  angle  or  l>y  alteration  of  the  constitution  of  the 
mtra-ociilai'  lliiiil. 


CHRONIC    GLAUCOMA    OR    NON-CONGESTIVE    GLAUCOMA         417 

As  alreadj'  pointed  out,  the  apposition  of  the  periphery  of  the  iris 
to  the  cornea  in  primary  glaucoma  may  at  first  be  unassociated  with 
inflammation;  but  if  the  apposition  is  long  continued,  proliferation  of 
the  endothelium  of  Descemet's  membrane  and  the  iris  takes  place  and 
these  two  layers  become  adherent.  Later  the  endothelium  in  large 
measure  disappears,  there  is  a  round-celled  infiltration  of  the  deeper 
corneal  layers  and  around  Schlemm's  canal,  the  tissue  cells  proliferate, 
and  the  iris  becomes  firmly  bound  down  at  its  new  position  at  the 
corneoscleral  junction.  In  the  early  stages  of  acute  primary  glaucoma 
the  ciliary  body  and  processes  are  engorged  and  swollen;  later,  and  in 
long-standmg  cases,  atrophy  and  shrmkmg  occur.  The  changes  in 
the  choroid  and  their  relation  to  the  pathogenesis  of  the  disease  and 
the  development  of  the  excavation  have  been  described.  While 
there  are  no  characteristic  changes,  as  a  rule,  in  the  retina,  in  advanced 
cases  atrophy  of  its  elements  are  visible,  and  endo-  and  perivascular 
changes  are  evident,  which  may  lead  to  hemorrhage.  As  already 
noted,  edematous  swelling  and  sometimes  actual  neuritis  precede 
cupping  of  the  nerve-head.  Later  there  is  backward  depression  of  the 
lamina  cribrosa  and  atrophy  of  the  optic  nerve-fibers.  .Alterations 
in  the  intrascleral  passage  of  the  venae  vorticosse  are  sometimes  dis- 
coverable, which  depend  upon  proliferation  of  the  endothelium  in  this 
position. 

Diagnosis. — It  is  of  the  utmost  importance  that  glaucoma  shall  be 
recognized,  if  possible,  in  its  very  incipiency.  The  most  usual  pro- 
dromal (early)  symptoms  are  a  frequent  desire  to  change  the  reading- 
glasses,  periods  of  obscuration  of  vision,  photopsies  and  the  halos 
surrounding  the  lamp-lights. 

The  glaucomatous  attack  itself  has  frequently  been  mistaken  for  a 
"cold  in  the  eye,"  for  iritis, — and  the  disease  has  been  aggravated  by 
the  instillation  of  atropin  or  other  mydriatic,  which  in  almost  all  cir- 
cumstances is  contraindicated, — for  neuralgia,  and  for  reflex  ocular 
pain.  The  condition  of  the  pupil,  the  diminished  depth  of  the  anterior 
chamber,  and  the  increased  tension  of  the  globe  are  the  symptoms 
which  should  prevent  so  fatal  an  error.  As  pointed  out  by  Parisotti 
and  Trousseau,  ophthalmic  migraine  sometimes  simulates  glaucoma, 
inasmuch  as  it  may  be  associated  with  increased  intra-ocular  tension, 
arterial  pulsation  in  the  fundus,  and  contraction  of  the  visual  field. 

The  differential  diagnosis  of  simple  chronic  glaucoma  and  atrophy 
of  the  optic  nerve  has  been  referred  to  and  presents  considerable  diffi- 
culty. The  absence  of  constant  increased  tension  in  the  simple  form 
of  the  disease,  or  at  least  its  doubtful  presence,  removes  an  important 
diagnostic  point.  Examination  with  the  tonometer  is  of  great  impor- 
tance in  these  circumstances.  Help  may  be  obtained  by  observing 
the  visual  fields.  In  glaucoma  the  color-fields  present  a  restriction 
corresponding  ^N-ith  that  of  the  white-fields,  while  in  atrophy  the  peri- 
pheral color  vision,  especially  for  red  and  green,  is  markedly  deficient. 
The  diagnostic  value  of  the  shape  of  the  field,  and  especially  of  the 
scotomas,  notably  Bjerritm' s  scotoma,  has  been  described  (see  page  404). 

27 


418  GLAUCOMA 

Examination  of  the  light-sense  is  important.  In  glaucoma  the 
"light  minimum"  is  said  by  some  observers  to  be  deficient,  but  the 
"light  difference"  not  far  from  normal;  in  pure  optic-nerve  atrophy 
there  is  imperfect  ability  to  distinguish  between  different  intensities 
of  illumination  ("light  difference").  (Compare  with  page  67  and 
see  also  page  401).  In  other  words,  according  to  Samelsohn,  the  light- 
perception  power  in  glaucoma  is  much  lessened,  while  the  light-differ- 
ence power  is  relatively  not  greatly  interfered  with;  in  optic-nerve 
atrophy  the  reverse  is  usually  the  case.  Wahlfors,  confirming  ob- 
servations made  long  ago  by  Mauthner  and  Forster,  insists  that  re- 
duction of  the  light-sense  is  one  of  the  most  frequent  symptoms  of 
simple  glaucoma,  and  that  night-blindness  may  first  call  the  patient's 
attention  to  his  eyes.  Moreover,  this  reduced  light-sense  may  exist 
for  j^ears  before  the  real  nature  of  the  disease  is  evident. 

It  is  an  inexcusable  error  to  confound  the  failing  vision  of  chronic 
glaucoma  with  that  of  cataract,  the  greenish  reflex  of  the  lens,  which 
may  be  seen  in  the  pupillary  space,  being  mistaken  for  an  opacity  of  the 
lens.  Eyes  have  been  permitted  to  pass  into  blindness,  and  their 
possessors  deluded  with  the  hope  that  they  were  waiting  for  the  ripen- 
ing of  a  cataract  which  never  existed.  An  ophthalmoscopic  examina- 
tion would  settle  the  diagnosis  at  once. 

Prognosis. — -Glaucoma  does  not  tend  to  spontaneous  cure,  but,  if 
unchecked,  to  blindness;  hence  the  prognosis  is  unfavorable  if  proper 
treatment  cannot  be  applied.  Prognosis  also  depends  upon  the  type 
of  the  disease  and  the  stage  of  its  development.  Other  things  being 
equal,  uncomplicated  acute  cases  furnish  the  most  reasonable  hope  of 
complete  cure,  and  if  a  technically  correct  operation  can  be  performed 
early,  the  result  is  usually  satisfactory.  In  chronic  cases  much  depends 
upon  the  amount  of  degenerative  change  in  the  tissues,  and  the  prog- 
nosis must  be  guided  b}'  the  state  of  vision,  the  extent  of  the  field,  and 
the  condition  of  the  iris.  The  earlier  treatment  (operation  or  other- 
wise) can  be  begun  in  this  as  well  as  the  acute  types  the  better  will 
be  the  result.  The  effect  of  treatment  upon  the  progress  of  glaucoma 
is  included  in  the  following  section: 

Treatment. — In  tlu^  majority  of  cases  of  acute  glaucoma  an  opera- 
tion is  needed  to  check  the  disease. 

It  may  happen,  however,  that  an  operation  is  not  at  once  possible  or 
advisable,  and  hence  the  miotics  should  be  quickly  and  thoroughly 
used.  In  the  early  stage  eserin  salicylate  or  sulphate  should  be 
employed  and  will  usually  relieve  the  symi)tonis.  In  acute  cases 
eserin,  in  a  strength  of  from  1  to  4  grains  (().()()')-  O.'JC)  gm.)  to  the 
ounce  (30  c.c),  acts  favorably,  and  often  with  suri)rising  rapidity, 
provided  tlie  pupil  responds  to  its  influence.  Pilocarpin  hydrochlo- 
rate,  2  to  ')  grains  (0.13-0.324  gm.)  to  the  ounc(>  (30  c.c),  may  be  sub- 
stituted. Miotics  act  l)y  drawing  tiie  iris  away  from  tlie  filtration 
angle,  and,  by  contracting  the  pupil,  cause  widening  of  the  spaces  of 
Fontana  and  absorption  of  the  tluid;  also  iris-surfaco  filtration  is 
increased  (see  also  page  411.)     A  diop  or  (wo  of  the  S(^l(>cted  solution 


CHRONIC    GLAUCOMA    OR   NON-CONGESTIVE    GLAUCOMA         419 

should  be  instilled  every  hour  or  two  until  relief  is  obtained;  if  this 
does  not  occur  promptly,  iridectomy  or  one  of  its  substitutes  should  be 
performed.  Arecolin  in  0.5  per  cent,  solution  has  also  been  used; 
with  this  drug  the  author  has  had  no  experience.  Dionin  and  adrena- 
lin chlorid  have  been  much  employed  in  the  treatment  of  acute 
glaucoma.  The  former  (in  5  per  cent,  solution)  often  acts  efficiently 
as  a  lymphagogue  and  analgesic;  the  latter  (1  :  10,000)  must  be  used 
with  caution,  as  occasionally  it  increases  the  intra-ocular  tension. 
It  may  be  added  to  the  solution  containing  the  miotic. 

In  addition  to  the  use  of  eserin  or  pilocarpin  during  an  acute  attack 
the  temple  may  be  leeched,  warm  fomentation  applied,  and  rest  and 
relief  from  pain  secured  by  the  exhibition  of  morphin  and  chloral,  the 
latter  drug  having  some  influence  in  reducing  tension.  Full  doses  of 
salicylate  of  sodium,  however,  act  more  favorably  than  any  other  con- 
stitutional remedy  (Sutphen,  Friedenwald) ;  indeed,  they  are  most 
useful  in  any  form  of  glaucoma  associated  with  pain.  An  interesting 
observation  of  oNIorax  is  that  reduction  of  tension  in  glaucomatous  eyes 
in  syphilitic  subjects  has  followed  the  injection  of  salvarsan,  an  ob- 
servation which  the  author  can  confirm.  To  lower  intra-ocular  ten- 
sion Fischer  and  Thomas  recommend  subconjunctival  injections  of 
sodium  citrate  (4.05-5.41  per  cent,  solution).  Of  these  solutions,  5  to 
15  minims  (0.30-0.92  c.c.)  are  injected,  and  if  the  injections  are  fre- 
quently employed,  the  weaker  of  the  two,  diluted  with  2  to  4  parts 
of  physiologic  salt,  is  employed. 

In  chronic  inflammatory  (subacute)  glaucoma,  eserin  (the  sulphate 
or  salicylate)  or  pilocarpin  should  be  employed  until  it  is  decided  what 
operation  shall  be  done  and  when  it  shall  be  performed.  The  other 
remedies  advised  in  the  preceding  paragraphs  are  also  useful  and  should 
be  employed. 

There  is  much  difference  of  opinion  in  regard  to  the  value  of  miotics 
in  the  treatment  of  chronic,  non-congestive  glaucoma.  In  the  opinion 
of  some  surgeons  who  deprecate  operation  in  this  form  of  glaucoma, 
they  represent  the  chief  therapeutic  measure,  while  in  the  opinion  of 
others  they  are  practically  without  value.  Neither  of  these  extreme 
views  is  correct.  That  miotics  can  hold  the  disease  in  check  for  long 
periods  of  time  cannot  be  doubted.  They  must  be  properly  used,  that 
is,  the  pupil  must  be  kept  contracted.  P  or  this  purpose  Posey  prefers 
salicylate  of  eserin,  beginning  with  a  solution  of  }{q  grain  (0.00648 
gm.)  to  the  ounce  (30  c.c),  and  gradually  increasing  the  strength  until, 
if  the  drug  has  continued  to  act  favorably,  at  the  end  of  three  years  the 
solution  has  a  strength  of  3  grains  (0.195  gm.)  to  the  ounce  (30  c.c). 
The  author  prefers  pilocarpin,  as  it  is  equally  efficient  and  less  irritat- 
ing; the  strength  should  usually  be  twice  that  of  the  eserin  solution. 
Conjunctival  irritation  can  generally  be  prevented  if  the  solutions  are 
always  fresh  and  sterile,  and  if  the  conjunctival  sac  is  frequently  irri- 
gated with  a  boric  acid  lotion. 

Massage  of  the  eyeball  is  of  distinct  advantage;  it  may  be  followed 
by  improvement  in  vision  and  deepening  of  the  anterior  chamber. 


420  GLAUCOMA 

Apparently  it  assists  the  action  of  the  miotics.  Usually  it  is  not 
possible  to  employ  it  in  acute  glaucoma,  but  in  simple  glaucoma  and 
in  eyes  ^vith  mild  attacks  it  certainly  temporarily  lowers  the  tension. 
It  may  be  applied  by  means  of  various  instruments  (see  page  281), 
that  is,  vibration  massage  f)r  with  the  helj)  of  suction  cup  (suction 
massage).  Just  as  good  results  can  be  obtained  by  simple  massage 
with  the  finger-tips.  Unfortunately,  the  value  of  massage  has  been 
unduh'  magnified  by  irregular  practitioners.  It  is  useful  only  as  an 
adjuvant  to  other  well-recognized  procedures,  operative  and  medicinal 
and  is  particularly  imix)rtant  in  the  post-operative  treatment  of  glau- 
coma. Strychnin  and  nitroglycerin  should  be  given  to  patients  with 
chronic  glaucoma,  especially  the  latter  drug  if  there  is  increased  vas- 
cular pressure.     High-frequency  currents  have  been  advised. 

Iridectomj^,  in  the  author's  opinion,  in  most  circumstances,  con- 
tinues to  be  the  most  satisfactory  operative  procedure  in  the  treatment 
of  acute  glaucoma.  It  should  be  performetl  early,  in  the  prodromal 
stage  if  possible,  while  the  excretory'  apparatus  is  still  intact  and  before 
the  root  of  the  iris  is  ivelded  to  the  cornea.  General  anesthesia  should 
be  induced  before  its  performance,  because  the  high  tension  of  the 
eyeball  somewhat  nullifies  the  action  of  cocain.  Much  depends 
upon  the  exact  position  of  the  iridectomy,  which  is  difficult  of  per- 
formance on  account  of  the  narrow  anterior  chamber,  and  no  caution 
should  be  omitted  which  will  secure  perfect  quiet  on  the  part  of  the 
patient. 

In  performing  iridectomy  for  the  relief  of  acute  glaucoma  the  follow- 
ing directions  should  be  borne  in  mind:  If  a  keratome  (Fig.  326)  is 
employed,  it  should  be  entered  through  the  sclerotic  coat  2  mm.  from 
the  apparent  border  of  the  cornea,  and,  after  the  comjiletion  of  the 
incision  (see  page  695),  should  be  slowly  withdrawn  in  order  to  prevent 
a  sudden  gush  of  aqueous  humor,  and  a  too  rapid  reduction  of  tension, 
which  might  be  followed  by  intra-ocular  hemorrhage.  If  the  anterior 
chamber  is  shallow  the  iridectomy  is  usually  more  easily  piM'formed, 
and  with  l)etter  results,  if  a  Graefe  cataract  knife  (see  Fig.  378)  is  em- 
ployed in  the  usual  manner  (see  page  730).  The  excision  of  the  piece 
of  iris  should  be  complete  up  to  the  periphery — /.  c,  up  to  the  ciliary 
border — and  no  portion  of  the  excised  iris  must  remain  in  the  angles  of 
the  wound  (compare  with  page  422).  This  is  a  much  more  important 
matter  than  the  excision  of  a  large  piece  of  the  iris — for  example,  one- 
fifth  of  it — as  is  u.sually  advised.  A  comparatively  narrow  technically 
correct  iridectomy  yields  satisfactory  results.  If  the  tension  is  very 
high,  preliminary  scleral  jnincture,  as  advised  by  Friestley  Smitli  and 
(lifford,  is  a  useful  |)r<)ce(hu-e.  It  .should  be  reniembenMJ  that  scleral 
puncture  has  been  followed  by  intra-ocular  hemorrhage  (A.  Knapp). 

A  favoral)le  result  may  l)e  exjiected  from  iridectomy  if  the  tension 
is  lowered;  an  unfavorable  one  if  this  reiiiaiiis  high.  It"  there  is  a  sud- 
den ri.se  of  tension  a  short  lime  after  the  o|)eration.  aci-cunpaiiied  by 
severe  j)ain,  there  is  reason  to  suspect  intra-ocular  hemorrhage. 
Maddox    recommends   absliaetion   of   lijood    from    the    nose,    that    is, 


CHRONIC    GLAUCOMA    OR    NON-CONGESTIVE    GLAUCOMA         421 

artificial  epistaxis  prior  to  operation  for  glaucoma  (also  cataract)  in 
dangerously  plethoric  individuals. 

Section  of  the  iris  is  sometimes  followed  by  an  extensive  hemorrhage 
into  the  anterior  chamber.  A  prolonged  effort  to  get  rid  of  this  blood 
should  not  be  made  lest  the  trituration  produce  cataract.  The  blood 
will  absorb,  although  it  may  take  many  days  and  even  weeks  before 
this  is  entirely  accomplished. 

The  reforming  of  the  anterior  chamber  is  sometimes  delayed  as 
long  as  a  week.  Occasionally  a  day  or  two  after  the  operation 
there  is  some  slight  rise  of  tension  in  the  eye,  which  is  of  temporary 
character. 

There  is  difference  of  opinion  as  to  whether  the  eye  should  be  ban- 
daged or  not  after  operations  of  this  character.  The  author  believes 
that  not  only  should  a  bandage  be  applied  for  the  first  few  days  to  the 
eye  upon  which  the  operation  has  been  performed,  but  also  to  the 
fellow  eye;  and  that  the  one  placed  upon  the  affected  organ  should 
remain  there  until  complete  restoration  of  the  anterior  chamber  has 
taken  place.  The  eye  which  has  not  been  operated  upon  should  be 
kept  thoroughly  under  the  influence  of  eserin  or  pilocarpin  during  the 
course  of  the  treatment,  because  it  is  well  known,  in  acute  glaucoma, 
that  iridectomy  may  be  followed  by  a  speedy  outbreak  of  the  same 
disease  in  the  opposite  eye.  In  most  instances  the  iridectomy  should 
be  placed  directly  upward,  so  that  the  overhanging  upper  lid  may  cover 
the  coloboma.  Should  the  primary  iridectomy  fail  to  reduce  the 
tension  permanently  it  may  be  necessary  to  reinforce  it  with  a  cyclo- 
dialysis or  an  anterior  sclerotomy  (see  page  699),  or  by  performing  a 
corneoscleral  operation. 

The  author  has  expressed  his  faith  in  the  efficacy  of  iridectomy  in 
acute  glaucoma.  Col.  Elliot  and  other  surgeons  decide  in  favor  of 
corneoscleral  trephining  or  other  operations  designed  to  establish 
permanent  filtration  in  the  acute  as  well  as  in  the  chronic  forms  of 
glaucoma. 

If  the  eye  which  has  not  been  subjected  to  operation  has  a  decidedly 
shallow  anterior  chamber,  and  if  there  is  a  history  of  so  called  pro- 
dromal glaucomatous  phenomena,  it  should  be  submitted  to  opera- 
tion as  soon  as  the  iridectomy  wound  in  the  opposite  eye  has  firmly 
healed,  certainly  before  the  patient  passes  from  skilled  observation 
because  it  is  practically  certain  that  it  will  be  attacked  like  its  fellow. 
If  the  signs  of  impending  glaucoma  are  not  clear  and  the  eye  is  never- 
theless suspected,  the  mydriatic  test  suggested  by  Edward  Jackson, 
Harlan,  and  Brailey,  which  consists  of  the  instillation  of  a  solution  of 
homatropin  and  noting  whether  it  produces  any  rise  in  intra-ocular 
tension  or  pulsation  of  the  vessels  of  the  fundus,  may  be  employed. 
Should  the  test  be  positive,  it  would  seem  proper  to  perform  at  once 
what  Treacher  Collins  has  called  a  preventive  iridectomy,  or,  following 
Col.  Elliot's  advice,  a  corneoscleral  trephining.  If  this  is  declined  or 
deemed  inadvisable,  the  patient  should  use  daily  a  solution  of  a  miotic 
(strong  enough  to  keep  the  pupil  contracted),  and  be  provided  with  a 


422  GLAUCOMA 

stronger  solution  to  be  used  in  an  emergency — i.  e.,  during  a  sudden 
attack.  If  both  eyes  are  affected,  both  should  be  operated  upon,  pro- 
vided the  conditions  are  suitable,  at  proper  intervals;  sometimes  in 
acute  cases  operation  on  one  eye  must  immediately  be  followed  by 
operation  on  the  other. 

One  of  the  complications  which  may  follow  the  operation  of  iri- 
dectomj"  in  glaucoma  is  the  formation  of  a  bulging  scar  at  the  seat  of  the 
incision,  sometimes  called  a  cystoid  cicatrix.  This  is  especiallj'  true  if 
due  care  has  not  been  taken  to  free  the  angles  of  the  wound  from  adher- 
ent iris.  On  the  other  hand,  in  severe  cases,  this  ver}'  cystoid  cicatrix, 
b}'  permitting  a  filtering  of  the  liquids,  has  been  regarded  as  a  favorable 
condition.  In  this  connection  the  modern  operations  for  the  relief  of 
glaucoma,  by  means  of  which  a  filtering  (fistulous)  area  is  produced, 
must  be  considered.     They  are  discussed  on  pages  700-706. 

The  treatment  of  chronic  congestive  (subacute)  glaucoma  is  less 
likely  to  be  followed  by  the  brilliant  results  seen  in  acute  cases;  and 
instances  are  on  record  in  which  after  the  performance  of  an  operation, 
entirely  correct  in  its  technic,  the  disease  has  not  been  stayed,  or 
malignant  glaucoma  (see  below)  has  resulted.  This  is  particularly 
true  if  degenerative  changes  have  occurred  in  the  iris.  Nevertheless, 
iridectomy  or  one  of  its  substitutes,  that  is,  corneoscleral  trephining, 
or  iridosclerectomy,  offers  the  patient  a  much  better  chance  than  if 
medicinal  measures  are  alone  relied  upon,  and  should  be  performed  as 
early  as  possible. 

There  is  much  difference  of  opinion  in  regard  to  the  value  of  iridec- 
tomy in  simple  glaucoma  (chronic  non-congestive  glaucoma),  and 
some  surgeons  doubt  the  propriety  of  its  performance  in  this  disease, 
and  depend  upon  miotics  and  certain  internal  remedies — -for  example, 
strj^chnin  and  nitroglycerin.  Statistical  information  indicates  that  in 
a  limited  number  of  the  cases  of  simple  glaucoma  submitted  to  iridec- 
tomy the  results  are  immediately  unfavorable — that  is,  the  disease  is 
not  only  not  checked,  but  rapidly  progresses  to  blindness;  in  a  fair 
percentage  of  cases  (15-45  per  cent.)  the  disease  remains  stationarj' — 
that  is,  the  iridectomy  maintains  the  condition  of  vision  which  was 
present  before  the  operation;  in  a  certain  number  of  cases  there  is 
temporary  amelioration,  but  later  slow  advance  of  the  disease — a  rate  of 
advance,  however,  that  is  slower  than  if  operation  had  not  been  per- 
formed; in  a  oomiiaratively  small  percentage  t)f  cases  the  operation  is 
followed  b}'  percept il)l('  and  permanent  improvement  in  vision. 

In  a  certain  number  of  cases  (Fried(>nwald  has  collec((>d  24,  18  of 
them  being  women)  a  j)erfectly  smooth  iriilectomy  is  followed  by  vuilig- 
narit  glaucotna.  The  symptoms  which  usually  api)ear  one  or  two  days 
after  the  iridectomy  are:  marked  increase  in  tension,  obliteration  of  the 
anterior  chamber,  iixation  of  the  colohoma,  ciliary  tenderness,  chemosis 
of  the  conjunctiva,  swelling  of  the  lids,  and  raj>id  loss  of  vision.  Hence 
Schweigger's  advice  to  operate  in  chronic  glaucoma  aHecting  both 
eyes,  first  upon  th(^  one  with  the  more  advanci>(l  disease,  even  if  it  is 
l)liri<l  is  followed  by  some  surgeons.      If  no  complication  arises,  there  is 


CHRONIC    GLAUCOMA   OR   NON-CONGESTIVE    GLAUCOMA        423 

reason  to  hope  that  iridectomy  on  the  fellow  eye  will  be  followed  by  a 
normal  healing  process.  Evidently,  this  rule  cannot  arbitrarily  be 
followed.  The  treatment  of  malignant  glaucoma  consists  in  the 
instillation  of  eserin,  or  posterior  sclerotomy,  and  the  administration  of 
large  doses  of  salicylate  of  sodium  (Friedenwald) . 

It  is  not  entirely  certain  how  iridectomy'  cures  glaucoma.  It  has 
been  suggested  that  this  is  accomplished  bj'  the  removal  of  the  por- 
tion of  tissue  which  closes  the  angle  at  the  anterior  chamber;  by  the 
moderation  of  the  blood-pressure  in  the  iris  (Exner) ;  by  the  filtration 
of  the  fluids  of  the  eye  through  the  hne  of  healing,  which,  for  this  rea- 
son, has  been  called  the  filtration  scar;  by  the  permanent  drain  which 
the  cut  surface  of  the  iris  affords,  inasmuch  as  it  is  not  closed  b}^  repara- 
tive processes  (Henderson).  The  details  of  performing  iridectomy  and 
sclerotomy  will  be  described  in  the  chapter  devoted  to  Operations. 

The  operation  of  sclerotomy  has  been  used  as  a  substitute  for  iri- 
dectomy, but  the  weight  of  testimony  in  favor  of  the  latter  operation 
is  sufl&ciently  great  not  to  make  it  a  more  desirable  mode  of  procedure 
than  iridectomy  except  in  selected  eases.  Every  iridectomj-  which  is 
peripherally  situated,  and  in  which  the  knife  enters  through  the  sclera 
some  distance  from  the  apparent  border  of  the  cornea,  is  in  itself  a 
sclerotomy.  It  is  useful  as  a  supplement  to  iridectomy  if  the  tension 
is  not  reduced,  and  may  be  employed  in  old  bhnd  glaucomatous  eyes  to 
reheve  pain.  According  to  the  late  Dr.  de  Wecker,  sclerotomy,  fol- 
lowed later  by  iridectomy,  which  can  then  be  performed  more  cor- 
rectl}^  owing  to  the  improved  state  of  the  eye,  is  preferable  to  a  primary 
iridectomy. 

In  recent  years  a  number  of  important  and  usually  satisfactory 
operations  have  been  devised  for  the  purpose  of  maintaining  a  filtering 
cicatrix  or  area,  and,  in  so  far  as  our  present  knowledge  enables  an 
opinion  to  be  formed,  their  permanent  results,  other  things  being  equal, 
are  much  more  satisfactor}'  than  the  simple  iridectomy  of  former  times. 
Of  these,  the  most  important  are  Lagrange' s  operation,  by  means  of 
which  an  iris-free  filtering  cicatrix  is  produced  with  a  combined  iridec- 
tomy and  sclerectoni}'  (see  page  700) ,  Herbert 's  wedge-isolation  operation 
(see  page  702),  trephining  the  corneoscleral  border  (Elhot's  operation, 
see  page  703),  and  sclerectomy  with  punch-forceps  [Holth]  (see  page  702); 
indocleisis  and  indotasis  (page  706).  The  value  of  Heine's  operation, 
or  cyclodialysis  (see  page  706),  in  the  treatment  of  glaucoma  has  been 
much  discussed  in  the  past  few  years;  but  it  is  e\'ident  that  while  it  has 
its  uses  it  cannot  replace  iridectomy  or  the  operations  just  referred  to. 
For  further  discussion  on  the  comparative  value  of  these  operations 
see  pages  700-707. 

The  operation  of  sympathectomy,  or  excision  of  the  superior  cervical 
ganghon  of  the  sympathetic,  for  the  rehef  of  glaucoma  has  been  per- 
formed a  number  of  times.  Little  is  heard  of  the  operation  at  the 
present  time,  and  evidently  it  has,  very  properly,  failed  to  secure  a 
permanent  place  in  ophthalmic  surgery. 

For  the  rehef  of  the  pain  of  absolute  glaucoma  opticociliary  neuro- 


424  GLAUCOMA 

iomy  has  been  performed,  and  is  still  advocatetl  jjy  some  surgeons. 
In  the  opinion  of  the  author,  enucleation  or  one  of  its  substitutes  is  a 
better  operation,  but  he  also  has  had  some  excellent  results  with 
cyclodialysis  and  from  corneoscleral  trephining;.  In  these  circum- 
stances, if  the  other  eye  shows  any  prodromal  signs  of  glaucoma,  it 
would  seem  proper  that  an  iridectomy  or  a  corneoscleral  trejihining 
should  be  performed  in  anticipation  of  the  glaucomatous  attack. 

The  association  of  glaucoma  with  various  constitutional  defects 
and  disturbances  of  metabolism  has  been  discussed  (page  409).  There- 
fore in  the  treatment  of  the  disease  local  medication  and  operative 
procedures  are  not  sufficient;  each  glaucoma  patient  should  be  thor- 
oughly examined  from  the  general  stand'point  and  remedies  and  dietetic 
regimen  ordered  according  to  the  findings.  Lagrange's  warning  that 
glaucoma  represents  a  ''sick  eye  in  a  sick  body"  nuist  not  go  unheeded. 

Secondary  glaucoma,  or  that  form  which  arises  in  consequence 
of  some  ])ie-existing  disease  of  the  eye,  may,  like  the  primary  variety, 
assume  an  acute  or  chronic  type. 

It  may  follow  inflammation  of  the  iris  and  ciliary  l)ody  with  the 
production  of  extensive  annular  synechite;  serous  cyclitis.  ulcers  of 
the  cornea  which  have  perforated  this  structure  and  produced  adherent 
cicatrices  or  staphylomatous  bulging;  swelling  of  the  crystalline  lens 
after  needling;  discission  of  after-cataract,  and,  occasionally.  i)rimary 
extraction  of  cataract;  dislocation  of  the  lens;  detachment  of  the 
retina,  associated  with  severe  hemorrhage;  the  growth  of  a  choroidal 
sarcoma  or  other  intra-ocular  tumor;  cysts  and  tumors  in  the  angle  of 
the  anterior  chamber  and  choroidoretinitis.  i)lastic  choroiditis. 
throm})Osis  of  the  central  retinal  vein,  and  disease  of  the  retinal  vessels. 
Mayou  calls  attention  to  the  early  formation  of  vessels  in  the  iris 
in  glaucoma  as  a  sign  of  thrombosis  of  the  central  retinal  vein  and 
to  the  dangers  of  operation  in  these  cases  because  it  may  be  followetl 
by  sulx'horoidal  hemorrhage.  Owing  to  injury  the  vitreous  may  pa.ss 
forward  into  the  anterior  chamber,  block  the  channels  of  exit,  or  i)ress 
against  the  iris,  and  thus  cause  secondary  glaucoma.  Adhesion  of  the 
lens  capsule  to  the  cornea  following  traumatism  or  cataract  extraction 
not  infre(iuently  results  in  secondary  glaucoma  (see  also  page  741). 

In  most  of  the  instances  mentioned  there  is  no  difficulty  in  diag- 
nosticating secondary  glaucoma  by  the  history  of  the  case  and  the 
knowledge  of  the  pre-existing  disease.  This  is  not  so  easy  if  flic 
original  trouble  has  been  deej)  in  the  eye,  for  exam])l(\  a  sarcoma.  In 
these  cases  the  glaucoma  is  usually  absolute 

Treatment.-  Sccondaiy  glaucoma,  in  general  terms,  recpiires  the 
.same  ticatnient  as  the  ])rimary  form  of  the  disease,  which  nuist  be 
modified  according  to  the  surrounding  ocular  conditions.  \  dislocated 
lens,  or  a  lens  swo11(mi  after  discission  for  cataract,  should  be  removed. 
Absolute  glaucoma  associat<'(l  with  gic.-it  ))ain.  if  there  is  any  suspicion 
of  iiit  ni-<»cul:ir  giowtli.  itidic-iles  excision  of  the  glol)e. 

Hemorrhagic  glaucoma  is  one  type  of  secoiid.-ny  gl:mc(ini;i  in 
wliicli  iiuiiierdiis  rel  iri;il  lieiiiol  lli;ig<'S  appe;ir  ;is  I  lie  result  <>t  I  luoiiibosis 


COMPLICATED    GLAUCOMA  425 

of  the  retinal  vessels,  or  hyaline  degeneration  of  their  walls,  or  other 
causes  likely  to  produce  extravasation  of  blood  (albuminuric  retinitis) . 
The  tension  rises  and  the  character  of  the  disease  may  be  acute,  sub- 
acute, or  chronic.  This  condition  should  be  sharply  differentiated 
from  primary"  glaucoma  associated  with  retinal  hemorrhages,  although 
sometimes  it  is  exceedingly  difficult  to  decide  whether  the  glaucoma  is 
secondarj'  to  the  hemorrhages,  or  whether  the  hemorrhages  have  been 
produced  by  alterations  in  the  tension  of  a  glaucomatous  eye.  With 
the  ophthalmoscope  one  may  see  the  ordinar}^  appearances  of  glaucoma 
and  numerous  retinal  hemorrhages;  or,  in  addition,  there  may  be  the 
lesions  of  the  disease  which  has  caused  the  hemorrhages  and  the  glau- 
coma which  followed  them.  Hemorrhage  into  the  vitreous  maj'-  occur, 
obliterating  the  fundus  reflex;  the  cornea  is  steamy,  the  anterior  cham- 
ber obliterated,  the  iris  discolored,  and  the  eyeball  intensely  injected 
and  very  hard. 

Iridectomy  is  not  usually  followed  by  good  results  in  hemorrhagic 
glaucoma  as  it  may  be  followed  by  intra-ocular  hemorrhage.  If 
attempted  it  should  be  preceded  by  posterior  sclerotomy.  Corneo- 
scleral trephining  has  been  tried  with  success;  cyclodialj^sis  has  been 
recommended  and  the  author  has  had  some  favorable  results  after  the 
procedure.  The  results  of  anterior  sclerotoni}^  are  more  favorable  than 
those  of  simple  iridectomy.  Posterior  sclerotomy  (tapping  the  vitreous) 
alone  ma}^  be  followed  by  relief,  and  cautious  paracentesis  of  the  an- 
terior chamber  was  advocated  bj'  Bull.  If  the  pain  becomes  intense 
and  bhndness  ensues,  enucleation  is  required.  General  treatment  is 
of  importance,  as  the  patients  are  usually  the  subjects  of  vascular  dis- 
ease and  high  arterial  tension:  the  cautious  use  of  cardiac  sedatives, 
nitroglj'cerin,  and  strict  regulation  of  the  diet  and  mode  of  life.  Lo- 
cally, measures  to  relieve  ocular  congestion  and  the  miotics  may  be 
employed;  dionin  and  holocain  often  afford  decided  relief. 

Complicated  Glaucoma. — Two  kinds  of  complicated  glaucoma 
are  described  which  may  be  looked  upon  as  varieties  of  the  secondary 
form  of  the  disease,  namely,  cataract  icith  glaucoma  and  high  myopia 
with  glaucoma.  In  the  former  condition  one  eye  alone  is  usually 
affected.  It  is  to  be  distinguished  from  the  lenticular  opacity  pro- 
duced by  absolute  glaucoma.  During  the  formation  of  cataract  glau- 
coma may  occur,  due  probably  to  swelling  of  the  lens  and  lessening  of 
the  circumlental  space,  and  it  is  important  to  test  frequently  the  intra- 
ocular tension  of  patients  with  developing  cataract;  preliminary  irid- 
ectomy may  be  required.  Glaucoma  which  develops  in  association 
with  absorptive  changes  in  a  senile  cataract  has  been  attributed  to 
toxic  products  brought  into  existence  by  this  process  (H.  Gifford). 

In  high  myopia  with  glaucoma  the  usual  changes  in  the  field  of 
vision  and  the  papilla  are  present.  In  addition  to  this  there  is  more 
or  less  choroidal  disturbance,  which  may  itself  be  the  cause  of  the 
glaucomatous  condition.  According  to  Hotta,  the  first  change  pro- 
duced by  the  increased  tension  is  an  excavation  of  the  nerve-head, 
and  subsequently  an  ectasia  into  the  intervaginal  space  of  the  im- 


426  GLAUCOMA 

mediately  surrounding  sclera.     The  relative  frequency  of  myopia  in 
glaucoma  has  been  referred  to  (page  409). 

Hydrophthalmos  (Hydrophthalmos  congenitus;  Keratoglobus; 
Megalocornea;  Buphthabnos;  Glaucoma  congenitum). — In  this  affection 
there  is  slow  but  progressive  enlargement  of  the  eye  in  all  its  diameters; 
the  cornea  is  flattened,  the  pupil  dilated  and  sluggish,  the  iris  atrophic 
and  sometimes  tremulous,  the  sclera  thinned  and  of  a  bluish  color, 
and  the  anterior  chamber  deepened;  the  intra-ocular  tension  is  raised. 
The  refraction  is  myopic,  but  not  to  as  great  a  degree  as  the  elongated 
axis  of  the  ej^eball  would  suggest,  because  as  Parsons,  who  has  studied 
the  subject  most  thoroughly,  points  out  the  flattening  of  the  cornea, 
the  flattening  of  the  lens  and  displacement  backward  of  the  lens  coun- 
teract the  axial  myopia.  In  the  course  of  time  the  cornea  may  be- 
come cloudy  (keratoglobus  turhidus),  although  this  is  not  usually'  the 
case  (keratoglobus  pellucidus).  The  papilla  may  be  and  usually  is  deeply 
cupped.  Fissures  in  DescemeVs  membrane  may  arise  and  appear  as 
lines  of  grayish  color  with  double  contour,  visible  to  the  corneal 
microscope. 

The  affection  appears  at  birth  or  shortly  afterward,  and  its  incipient 
stages  are  believed  to  be  intra-uterine.  The  precise  cause  is  not  accu- 
rately determined.  Buphthalmos  is  more  frequent  in  negroes  than 
in  white  children,  perhaps,  as  Zentmayer  suggests,  on  account  of  the 
greater  frequency  of  congenital  syphilis  among  them.  It  has  been 
ascribed  to  an  intra-uterine  iridokeratitis  with  increased  intra-ocular 
tension;  in  other  words,  a  form  of  congenital  glaucoma.  Pyle  divides 
the  disease  into  two  classes:  true  hydrophthalmos,  depending  upon 
congenital  defective  development  of  the  cornea,  iris,  or  filtration 
channels,  and  hydrophthalmos  secondary  to  fetal  intra-ocular 
inflammation. 

The  prognosis  is  unfavorable;  the  afiection  usually  progresses  to 
blindness.  Iridectomy  has  been  practised  sometimes  with  a  good 
result,  more  often  with  poor  success  and  on  the  whole  is  not  advisable; 
some  favorable  results  from  repeated  sclerotomies  have  been  reported; 
indeed,  Haab  states  that  if  these  procedures  are  begun  earlj-  enough, 
infantile  glaucoma  can  be  cured.  Subconjunctival  paracentesis  has 
been  advised.  Corneoscleral  trephining  has  been  recommended,  and 
practised  with  encouraging  results  (Calhoun,  Zentmayer,  Elliot). 
The  technic,  as  Elliot  points  out,  of  corneoscleral  operation  in  this 
disease  differs  in  some  respects  from  that  in  ordinary  glaucoma  (page  • 
703).  The  author  has  observed  in  one  case  beneficial  effect  from  this 
procedure.     Eserin  or  pilocarpin  should  be  tried. 


CHAPTER  XIII 


DISEASES  OF  THE  CRYSTALLINE  LENS 


Congenital  Anomalies. — In  addition  to  congenital  cataract  and 
congenital  displacement  of  the  lens,  which  are  described  on  pages  436 
and  448,  two  anomalies  require  mention: 

1.  Coloboma  of  the  Lens. — This  defect  occurs  usually  with  a  sim- 
ilar defect  in  the  iris  and  choroid.  The  normal,  rounded  margin  of  the 
lens  is  replaced  by  a  straight  margin  in  a  horizontal  direction  or  in- 
curved. The  amount  of  the  defect  varies  from  a  shght  indentation  to 
about  one-quarter  of  the  lens  substance.  It  is  almost  always  situated 
in  the  inferior  half  of  the  lens.  A  defect  in  the  zonule  of  Zinn  has 
been  recorded  {coloboma  of  zone  of  Zinn) ;  also  a  general  smallness  of 
the  lens  {microphakia) . 

2.  Lenticonus. — Posterior  lenticonus  is  an  abnormal  curvature  of  the 
posterior  surface  of  the  lens  or  an  anomaly  of  the  nucleus  (L.  jMiiller), 
either  unilateral  and  associated 

with  lenticular  opacities,  or 
without  such  association,  and 
then  usual] 3^  bilateral.  With 
the  plane  mirror  a  sharp  red 
disk,  surrounded  by  dark  shad- 
ows, like  an  oil-globule  in  water, 
may  be  seen  (Knapp) .  A  nterior 
lenticonus  is  a  rare  anomaly, 
and  may  be  bilateral,  as  in  a 
case  studied  by  the  author  and 
Mej'er  Wiener,  where  each  lens 
presented  a  pronounced  cone, 
the  tip  of  which  almost  touched 
the  posterior  surface  of  the 
cornea  (Fig.  192).  Verhoefif 
suggests  a  cone  of  this  character  may  be  due  to  persistence  of  the 
conical  shape  of  the  embryonic  lens  vesicle  or  to  delayed  separation  of 
the  lens  from  the  cornea.  According  to  Tscherning  anterior  lenticonus 
and  shallowing  of  the  anterior  chamber  take  place  during  the  act  of 
accommodation. 

Congenital  aphakia,  in  association  with  the  faulty  development  of 
the  anterior  part  of  the  globe,  has  been  reported;  it  may  also  result 
from  the  absorption  and  degeneration  of  a  previously  formed  lens. 

Cataract. — Under  the  term  cataract  are  included  several  types  of 
an  opaque  condition  of  the  crystaUine  lens,  of  its  capsule,  or  of  both 

427 


'^HHi(fH^t<^ 


Fig. 


192. — Posterior  lenticonus  (from  a  patient 
in  the  University  Hospital). 


428 


DISEASES    OF    THE    CRYSTALLINE    LENS 


these  structures,  which  anatomically  are  distinguished  l)y  the  titles 
lenticular,  capsular,  and  capsulolcnticular. 

Varieties  of  Cataract. — (1)  Primary;  (2)  secondary  to  disorders  in 
other  portion?;  of  the  eye;  (3)  symptomatic  of  a  general  malady  or  local 
injury. 

A  cataract  is  either  partial  and  stationary,  or  progressive  and  be- 
comes complete,  and  clinically  is  classified  as  senile,  subdivided  into 
nuclear  and  cortical;  or,  according  to  Axenfeld,  subcapsular,  supranu- 
clear, and  nuclear;  juvenile  or  presenile;  congenital,  subdivided  into 
complete  or  partial;  secondary  or  complicated;  traumatic;  and  after- 
cataract. 

Cataracts  are  also  classified  according  to  their  consistence  as  hard, 
soft,  or  fluid,  and  sometimes  are  designated  by  their  color  as  black, 
white,  amber,  etc.  Blue  cataracts  are  occasionally  encountered 
(cataracta  ccerulea).  Although  in  many  instances  the  precise  division 
of  cataract  into  special  varieties  may  be  unimportant,  the  following 
table,  compiled  from  the  classifications  employed  in  various  standard 
works,  may  be  useful  to  the  student. 


Anatomically 


Clinically 


Lenticular. 

Capsular. 

Capsulolcnticular. 
(a)  cortical 
{h)   nuclear 

Juvenile  or  presenile. 


Senile 


general. 


3.  Congenital 


(o)  complete 


(6)  partial 


4.  Complicated  or  secondary 


5.  Traumatic, 
f).   Aftfr-ratarnct. 


complete. 

congenital. 

lamellar,  or  zonular. 

axial,  or  coralliform. 

punctate. 
I  discoid. 

I  pyramidal,  or  polar. 
r  anterior  polar  cataract. 
j  posterior  polar  cataract. 
•i  anterior  cortical  cataract. 
I  posterior  cortical  cataract. 
I  complete  cataract. 


Symptoms.  -'V\\v  I'ollowiti.i;  syini)toms  arc  present  with  more  or  less 
constancy  in  cataract,  e.\eni])lifie(l  by  the  senile  foini  of  this  disease: 

1.  Change  in  Visual  Aculencss. — Tlie  amount  of  dei)reciation  of 
sight  depends  upon  the  situation  and  extent  of  the  opacity,  and  some- 
times upon  alterations  in  the  refractive  power  of  the  lens.  Thus  there 
may  be  an  increase  in  the  ind(>x  of  refraction  of  the  crystalline  lens  as 
an  accomi)aninient  of  structural  change  in  advancing  years,  causing 
myo])ia,  often  called  prodronial  myopia.  In  these  circumstances 
distant  vision  is  iniproveil  by  concave  lenses  and  reading  becomes 
possible  without  thi'  aid  of  conv(;x  glasses.  This  is  the  .so-caTled 
"s<'<'""d  sight."  Such  cliaiiges  in  the  1(mis  may  cause  a  halo  to  aj)[H'ar 
around   a  TTglit ,   foi-  example   an   electric    light    bull).      Accoiding   to 


CATARACT 


429 


Landolt  this  halo  is  not  visible  around  all  lights  indiscriminately,  but 
around  such  as  are  situated  at  a  given  distance.  It  is  due  to  the 
dispersion  which  luminous  rays  undergo  in  the  equatorial  region  of 
the  crystalline  lens;  the  halo  disappears  if  the  light  is  looked  at  through 
a  pin  hole  disc.  Changes  in  the  lens  may  produce  an  irregular^stig; 
matism,  or  an  astigmatism  "against  the  rule"  may  develoj)^ 
^         ^  by 


2.  HyperemlaTof^e  ^UotijuncUva. — Tliis~is  caused^  by  the  strain 
which  the  effort  to  see  through  a  somewhat  clouded  lens  produces. 


Fig.    193. ^Anterior  lenticonus  (from  a  patient  in  U.  S.  General  Hospital  No  30). 


3.  Pain  and  Photophobia. — These  symptoms  are  not  prominent; 
but  sometimes,  owing  to  the  condition  of  disturbed  choroid  which  com- 
monly is  associated  with  cataract,  patients  complain  of  dull,  aching 
pain  or  other  asthenopic  symptoms.  Tinted  glasses  relieve  the  photo- 
phobia and  permit  sHght  dilatation  of  the  pupil,  which  sometimes  im- 
proves vision  if  the  opacity-  is  central.  Pain,  with  rise  of  tension  on 
account  of  swelhng  of  the  lens,  occasionally  occurs.  Indeed,  acute 
glaucoma  may  be  caused  by  this  swelhng  of  the  lens  during  the  forma- 
tion of  cataract,  and  the  state  of  the  intra-ocular  tension  deserves  close 
attention  in  all  patients  with  formed  or  forming  cataract. 


430  DISEASES    OF   THE    CRYSTALLINE    LENS 

4.  Polyopia  and  monocular  diplopia  are  occasionally  the  result  of 
incipient  cataract,  and  are  due  to  the  irregular  astigmatism  which  the 
alterations  in  the  lens  have  produced. 

5.  The  Anterior  Chamber. — This  may  be  normal  in  depth — the  usual 
condition  in  incipient  and  mature  cataract;  shallower  than  normal — 
indicating  a  swollen  lens;  or  abnormally  deep — a  symptom  of  a  small 
lens. 

6.  The  Pupil. — This  may  be  natural  in  appearance  and  the  mobihty 
of  the  iris  entirely  normal;  but  sometimes  the  effect  of  exclusion  of 
light  or  of  a  mydriatic  fails  to  induce  a  dilatation  of  the  pupil. 

We  speak  of  the  "color  of  the  pupil,"  and  this  varies  in  cataract 
according  to  the  degree  of  maturity  and  the  hue  of  the  opacity.  Hence 
in  the  unilluminated  pupil  no  change  is  seen  in  its  color  in  incipient  cata- 
ract; but  in  a  ripe  cataract  the  pupillary  space  may  appear  dull,  gray, 
and  even  white,  according  to  circumstances.  In  examples  of  so-called 
"black  cataract"  the  pupil  is  dark.  The  mere  inspection  of  the  pupil, 
however,  without  optical  aid  is  not  sufficient  to  ascertain  the  condition 
of  the  lens,  which  continues  to  increase  in  size  even  with  advancing 
years,  if  it  remains  clear.  But  it  becomes  firmer,  straw  colored,  and 
reflects  more  light.  This  creates  a  dull  sheen  in  the  pupil  which  may 
be  mistaken  for  cataract.  The  yellowish  tint  of  the  lens  in  advanced 
life  may  modify  the  relative  perception  of  colors,  which,  indeed,  may 
be  so  pronounced  as  to  create  blue-blindness  (C.  Hess). 

Diagnosis. — From  what  has  been  said,  it  is  apparent  that  the  abso- 
lute diagnosis  of  cataract  depends  upon  the  use  of  the  ophthalmoscope. 
Since  the  introduction  of  the  ophthalmoscope,  the  catoptric  test  has 
fallen  into  disuse,  although  it  may  be  employed  to  determine  the 
presence  of  the  lens  and  in  the  diagnosis  of  black  cataract. 

This  test  is  performed  as  follows:  If,  in  a  dark  room,  a  lighted 
candle  is  moved  before  a  healthy  eye  with  dilated  pupil,  three  images 
of  the  flame  will  be  seen:  two  erect,  formed  by  reflection  from  the 
convex  cornea  and  anterior  surface  of  the  lens,  the  former  producing  the 
bright  image  and  the  latter  the  more  diffuse;  and  one  inverted,  rela- 
tively clearer,  from  the  posterior  surface  of  the  lens.  If  the  lens  is 
opaque  the  inverted  image  is  wanting,  the  deeper  erect  image  also  dis- 
appearing when  the  opacity  involves  the  capsule,  the  corneal  image 
being  then  alone  visible. 

B('f()r(>  using  the  oijhthalnioscope  for  (ho  detection  of  cataract  the 
pupil  should  be  dilat(Kl,  preferably  with  h<)nia(r()i)in,  cocain,  or  euph- 
thalmin.  The  examiner  proceeds  in  I  he  manner  described  on  page 
103,  and  will  detect  in  incipient  cataract  spots  or  streaks  of  opacity, 
often  radiating  from  the  peri])hery  toward  the  center,  which  ai>pear 
blatik  from  th(i  inteifcrcnce  with  (he  rcdcM^ion  of  light  from  (h(^  choroid. 
In  like  manner  the  nucleus  ma^'  be  seen  (t)  !>(>  hazy  and  (he  peripluM-y 
clear,  or  the  sectors  of  the  lens  are  strongly  marked.  The  beginning 
of  cataract  is  also  made  evident  by  flaws  in  (he  l(>ns,  which  hav(>  been 
comj)an'd  (o  cracks  in  glass,  and  are  known  as  "s(ria>  of  rcfrac(ion." 
If  (he  (■n(ire  lens  is  opa(iU(',  no  por(ion  of  the  pupillary  s])ac«'  exhibits 


CATARACT 


431 


any  red  reflex  from  the  fundus,  although  a  lens  which  appears  com- 
pletely cataractous  tlirough  the  undilated  pupil  maj'  exhibit  spots  of 
incomplete  opacification  in  the  peripherj-  recognized  by  the  transmitted 
red  glare  when  the  pupil  is  dilated.  The  final  examination  with  trans- 
mitted light  should  be  made  with  a  +  16  D  lens  or  with  a  corneal  loupe. 

With  oblique  illumination  (see  page  51)  the  opacities,  if  incipient, 
appear  as  white  or  gray  streaks  and  dots. 

When  a  progressive  senile  cataract  is  fully  matured,  its  presence 
maj^  often  be  detected  without  any  special  examination  except  in  the 
instances  already  mentioned,  but  it  is  a  matter  of  the  utmost  impor- 
tance to  ascertain  wheri  this  full  maturity'  has  been  reached,  or,  in  other 
words,  whether  the  cataract  is  ripe.  This  is  determined  in  the  follow- 
ing manner: 


Fig.  194. — Cortical  cataract:  1,  Section  of  lens,  opacities  beneath  the  capsule; 
2,  opacities  seen  by  transmitted  light  (ophthalmoscope  mirror) ;  3,  opacities  seen  by 
reflected  light  (oblique  illumination)    (modified  from  Nettleship). 


The  patient  being  placed  in  the  proper  position,  the  pupillary  space 
is  illuminated.  If  the  opacity  is  complete,  the  opaque  lens,  covered  by 
its  capsule,  is  level  with  the  margin  of  the  pupil,  and  there  is  no  shadow; 
if  not,  the  major  portion  of  the  opacity  is  at  a  level  posterior  to  the 
plane  of  the  pupil,  or,  in  other  words,  a  clear  or  partly  clear  space  is 
present  betw^een  the  iris  and  the  opaque  portion,  and  a  dark  semicircle 
appears  upon  the  opacity  at"  the  side  from  which  the  light  comes. 
This  is  the  shadow  of  the  iris.  Shining  sectors  or  the  transmission  of 
a  red  glare  indicate  immaturity,  even  if  the  shadow  is  absent.  In 
hypermature  cataract  the  shadow  is  visible,  but  the  surface  of  the  lens 
is  flat. 

Development,  Course,  and  Pathologic  Anatomy  of  Cataract. — In 
progressive  senile  or,  as  it  is  sometimes  called,  simple  cataract  there  is  a 
period  of  growth  from  incipiency  to  full  maturity  which  varies  con- 
siderably, and  ordinarily  consumes  from  one  to  three  years.  Often 
the  rate  of  increase  is  xexy  slow,  and  immature  cataract,  especially  of 
the  cortical  variety,  may  remain  unchanged  for  many  years.  At  other 
times  the  development  of  the  disease  is  comparatively  rapid.  This 
slow  progress  of  cortical  senile  cataract  should  be  remembered,  and  the 
discovery  of  striae  in  the  lens  need  not  condemn  the  patient  to  rapid 


432 


DISEASES    OF   THE    CRYSTALLINE    LENS 


cletorioiation  of  vision.  Indeed,  certain  lenticular  opacities  remain 
practicallj-  stationary  for  years. 

The  opacities  begin  either  equotoriaUy — i.e.,  at  the  edge  of  the  lens 
— or  ceniraUy — /.  c,  at  the  nucleus.  In  the  former  case  the  slriie  begin 
just  beneath  the  capsule  and  are  seen  both  in  the  anterior  and  posterior 
cortex.  Sometimes  broad  sector-shaped  opacities  form,  or  the 
opacities  may  be  narrow,  or  they  may  appear  as  delicate  radiating 
lines.  They  gradually  radiate  toward  the  center  (encroach  on  the 
pupil  space),  the  nucleus  becomes  hazy  and  sclerosed,  the  cortical 
layers  become  swollen,  more  opacjue,  and,  finally,  the  cataract  is 
complete.  Cataract,  other  things  being  equal,  is  more  prone  to  begin 
in  the  lower  part  of  the  lens  than  elsewhere. 

In  the  second  variety  the  nucleus  becomes  hazy  and  the  smround- 
ing  cloudiness  always  remains  the  most  opaque  portion  of  the  cataract, 
which  gradually  spreads  to  the  cortex  (Fig.  195).  Where  diffuse 
clouding  occurs  first  at  the  central  portion  of  the  lens,  that  is,  in  the 
layers  immediately  surrounding  the  nucleus,  mark(>d  depreciation  of 
vision  is  an  early  symptom. 


Fiu.  l\)o.  Nuclear  cataract:  1,  Section  of  leu.s,  central  i.>u.~iuoii  of  opacity;  2, 
appearance  by  transmitted  light;  3,  appearance  by  oblique  illumination  (modified  from 

Nettleship). 

A  frequent  lesion  is  a  disk  of  opacity  with  irr(>gular  borders  in 
the  posterior  layers  of  the  cortex,  web-like  in  struct  inc.  or  sometimes 
looking  like  a  collection  of  minute  l)ul)])les  and  stri;e.  This  also  causes 
marked  disturjjance  of  vision. 

To  a  ring  of  opacity  near  the  eqiuitor  of  the  lens  and  behind  the 
iris,  seen  in  old  persons  and  frequently  stationary  for  long  periods  oi 
time,  the  name  arcus  senilis  /cn//.s  has  b(>en  given. 

Cataract  may  also  begin  as  a  more  or  less  diffuse  clouding  or  in  the 
form  of  small  dots,  or  blislei-like  bodies,  scattered  through  tlie  cortex, 
or  located  either  in  llu'  aniciioi'  or  |)osteiior  cortex,  or  in  opacities 
which,  with  Iransniilted  liglil,  icsenible  diiik  tlocculent  precii>itates. 
In  the  last-named  circumstances  the  advance  is  more  rapid  than  where 
the  stria'  are  the  first  manifestation.  Instead  of  going  on  to  maturity, 
a  nut^lear  haze  oi-  a  sjjeai-  of  opacity  nuiy  remain  stationary,  or  at  least 
show  no  practical  change  for  years.  Very  exceptionally  an  anterior 
capsular  opacitw  not  to  lie  conrused  with  such  an  opacity  as  occiu's  in 


CATARACT  433 

hypermature  cataracts  or  as  is  described  on  page  412,  precedes  the 
development  of  lenticular  cataract  by  a  long  period  of  years. 

These  various  stages  of  cataract  development  are  often  classified 
by  systematic  writers  into  (a)  the  stage  of  incipiency  (early  cataract) ; 
(6)  the  stage  of  swelling  (intumescent  cataract) ;  (c)  the  stage  of  maturity 
(ripe  cataract);  (d)  the  stage  of  hj^permaturity  (overripe  cataract). 

During  the  formation  of  cataract  the  following  changes  occur  in  the 
lens:  First,  there  is  a  separation  of  the  lens-fibers  with  a  collection  of 
fluid  between  them,  which  coagulates  into  drops — the  spheres  of  Mor- 
gagni.  Later  there  are  swelling,  clouding,  and  fatty  degeneration  of 
the  cortical  fibers  and  the  formation  in  them  of  nucleated  vesicular 
bodies.  Ultimately  there  is  disorganization  of  the  fibers,  and  the 
lenticular  tissue  is  changed  into  fat-drops,  spheres  of  ^Nlorgagni,  and 
albuminous  liquid,  and  the  cortex  separates  from  the  capsule,  the 
liquor  IMorgagni  collecting  between  them.  The  lens  nucleus  becomes 
sclerosed,  but  in  other  respects  is  not  greatly  altered.  Paul  Romer  has 
studied  the  pathogenesis  of  cataract  from  the  point  of  view  of  serum 
investigations,  and  believes  it  is  possible  that,  as  a  result  of  the  de- 
generative processes  of  old  age,  antibodies  are  liberated  in  the  blood 
which  possess  a  definite  affinity  for  certain  parts  of  the  lens  protoplasm. 
They,  by  uniting  with  corresponding  receptors  of  the  lens  protoplasm, 
are  able  to  damage  the  lenticular  cells,  just  as  blood-corpuscles  are 
destroyed  by  the  union  with  them  of  specific  cytotoxins. 

^Maturity  may  be  succeeded  by  the  stage  of  "  overripeness "  and 
the  cataract  gradually'  shrinks  to  a  flat  disk,  or  the  later  liquefaction 
of  the  cortical  matter  permits  displacement  of  the  nucleus,  which  may 
be  brown,  yellow  or  quite  dark  in  color.  Examination  fails  to  reveal 
striae  or  sectors;  whitish  dots  may  be  visible.  Still  later  the  cataract 
has  a  uniform  white  appearance,  sometimes  a  slight  bluish  tint,  a  type 
which  is  known  as  Morgagnian  cataract.  Tremulousness  of  the  iris  is 
seen  in  overripe  cataracts.  S-pontaneous  rupture  of  a  ^Morgagnian  cata- 
ract has  been  reported  (Gonzalez).  Sometimes  calcareous  degenera- 
tion in  the  lens  or  its  capsule  may  take  place  and  a  patch  of  capsular 
opacity  is  not  uncommon  in  old  and  sometimes  overripe  cataracts. 

The  cataract,  the  development  of  which  has  just  been  described,  is, 
for  the  most  part,  hard — i.  e.,  the  nucleus  of  the  lens  is  large.  Under 
the  age  of _  thirty-five  all  cataracts  are  soft — i.  e.,  the  nuclei  are  small 
or  wanting,  just  as  the  lenses  in  which  they  develop  haye  failed  to 
attain  the  density  which  later  thej'  assume. 

Causes  of  Cataract. — 1.  Age  of  Life. — Cataract  which  becomes 
complete  is  especially  frequent  after  fifty  years;  but,  as  Fuchs  remarks, 
it  cannot  be  regarded  as  a  physiologic  attribute  of  old  age.  It  is  a 
pathologic  process,  and  age,  while  it  is  an  important  factor  in  its  devel- 
opment, must  often  be  regarded  only  as  a  predisposing  cause.  Occa- 
sionally total  cataract  without  apparent  constitutional  disease  is  found 
in  adolescents.  The  very  beginnings  of  cataract,  according  to  one 
observer,  are  not  peculiar  to  old  age,  but  appear  between  the  twentieth 
and  the  thirtieth  year  as  an  equatorial  cataract. 

28 


434  DISEASES    OF   THE    CRYSTALLINE    LENS 

2.  Sex. — Thifs  appears  to  have  no  docided  influcnco.  the  sexes  being 
about  equally  affected,  unless  it  be  in  the  zonular  variety,  in  which  a 
greater  liability  of  females  has  been  recorded. 

3.  Disease. — Sugar  has  been  found  in  the  urine  of  about  1  per  cent, 
of  cataract  cases,  and  the  cataractous  lenses  of  patients  the  subjects 
of  diabetes  mellitus  at  times  contain  sugar.  According  to  Klein, 
posterior  polar,  combined  with  posterior  cortical  cataract,  unassoci- 
ated  with  choroiditis,  is  significant  of  diabetes.  Schanz's  experiments 
indicate  that  the  presence  of  sugar  and  acetone  aid  the  action  of  light 
in  causing  cataract.  AU^uniin  is  present  in  about  0  per  cent,  of  the 
cases,  but  the  etiologic  relation  of  nephritis  to  cataract  has  not  been 
proved.  Grilli's  researches  lead  him  to  believe  that  cataract  is  caused 
by  a  species  of  dehydration  of  the  lens,  brought  about  by  an  insufficient 
elimination  of  solids  by  the  kidneys,  and  a  consequent  rise  of  osmotic 
tension  in  the  blood  and  aqueous  humor.  Doubtless,  changes  in  the 
osmotic  pressure  of  the  fluids  circulating  around  the  lens,  whether  they 
are  due  to  toxic  causes  or  local  disease,  contribute  to  the  formation 
of  cataract,  although  Romer  has  shown  that  they  may  vary  greatly 
without  affecting  the  lens. 

Cataract  has  also  been  noted  in  connection  with  idiopathic  fevers 
and  allied  diseases,  with  gout,  malaria,  influenza,  rachitis,  syphilis 
(Bos),  angiosderosis,  and  espc'ciall}^  atheroma  of  the  carotid  (Michel), 
epilepsy,  and  other  convulsive  seizures,  meningitis  (Bock),  certain 
cutaneous  affections  (Mooren,  Kotlunund,  Andogsky — dermogenetic 
cataracts),  with  bronchocele,  wdth  hookworm  disease  (Calhoun),  and 
sea-sickness  (Weeks).  As  Becker  has  stated,  however,  a  connecting 
link,  in  many  instances,  between  constitutional  maladies  and  opacities 
of  the  crystalHne  lens  has  not  been  established.  Th(>  fre(iuencv  with 
which  lenticular  opacities,  either  cortical  or  at  the  posterior  pole,  ap- 
pear in  eyes  the  retinal  arteries  of  which  show  signs  of  degeneration 
(see  page  497)  is  well  known.  The  late  D.  W.  Greene  studied  the 
rcilationship  between  increased  l)lood-pressure  and  the  fornuition  of 
cataract,  and  believed  that  increased  arterial  tension  exerti'd  a  certain 
influence  in  the  causation  of  lenticular  opacities.  It  is  possible  that 
sclerotic  changes  in  the  nutrient'  vessel  of  the  anterior  uveal  tract 
may  aid  in  Ihe  development  of  lenticular  degeneration.  Schiotz  has 
descrilx'd  a  rclalionsliip  Ix'tween  cataract  and  disturl)anc('s  of  internal 
secretion.  Tlie  association  between  myotonia  atrophica  ami  cataract 
(opacities  deep  seated  and  irregular  [L.  Paton])  has  been  noted.  They 
and  the  myotonia  are  probably  due  to  the  same  nu^tabolic  dcfiH't.  ,1. 
Fischer  and  O.  Ti-ienenstcin  investigating  a  number  of  senil(>  and  pre- 
senile catara(tt  patients  to  discover  evidences  of  tetany,  or  latent  te- 
tany, found  such  evidence  in  SS  ])er  cent,  of  the  cases;  also  pnMnature 
grayness  of  the  liaii-,  dryness  of  the  skin,  etc.  Peters  has  also  attrilt- 
utcd  some  nuclear  cataracts  to  tlie  toxin  of  tetany. 

4.  Occupation.  Cataract  is  especially  friMiueut  among  glass- 
blowers,  and  is  attrii)Uted  to  the  effect  of  tiu>  ladiated  he;il  and  <'XC(>s- 
sive  perspiration.     In  hollh  -mtiLt  is'  vulitntcl  the  lesions  often  consist 


CATARACT  435 

of  a  dense,  well-defined  disk  of  opacity  in  the  center  of  the  posterior 
cortex,  surrounded  by  smaller  opacities.  It  is  not  improbable  that 
additional  investigations  such  as  the  author  made  years  ago  would 
show  the  same  liability  to  cataract  in  puddlers  and  others  exposed  to 
intense  heat;  indeed,  Cridland  has  observed  in  furnace-workers  cata- 
ract resembling  that  which  is  frequent  in  glass-blowers,  to  which  the 
name  jurnace-workers'  cataract  has  been  given. 

5.  Heredity. — Remarkable  examples  of  the  influence  of  heredity  in 
the  formation  of  cataract  have  been  published.  It  has  been  noted 
that  the  tendency  is  more  marked  in  the  child-bearing  period,  and  that 
the  transmission  is  through  the  female  line ;  transmission  through  the 
male  line  only,  however,  has  been  recorded.  All  phases  of  this  subject 
were  elaborately  studied  by  the  late  Mr.  Nettleship.  In  both  groups 
of  acquired  cataract,  that  is,  senile  and  presenile  or  juvenile  cataract, 
the  transmission  is  almost  always  direct.  Occasionally  a  generation 
is  skipped.  Referring  to  the  frequency  of  inherited  cataract,  he  found 
that  women  are  somewhat  more  liable  to  familial  acquired  cataract 
than  men.  In  cataract  families  the  lenticular  opacities  may  appear 
among  the  descendants  at  the  same  age,  or  the  succeeding  generation 
may  be  affected  earlier  than  the  preceding  one  (anticipation). 

6.  Toxic  Agents. — Cataract  has  been  produced  artificially  by  poi- 
soning rabbits  with  naphthalin  {naphthalin  cataract),  sodium  nitrate, 
and  other  toxic  agents.  In  addition  to  the  cataract,  there  are  changes 
in  the  retina  and  vitreous  and  also  general  disturbances. 

During  epidemics  of  ergotism  patients  are  at  times  afifected  with 
cataract  {raphanic  cataract) ,  the  appearance  having  been  noted  almost 
exclusively  in  the  convulsive  type  of  this  toxemia;  hence  it  is  not  cer- 
tain whether  the  lenticular  opacity  results  from  the  poisoning  by  the 
ergot  or  on  account  of  the  convulsions. 

7.  Traumatism. — Cataract  may  follow  a  direct  injury  to  the  lens, 
or  be  caused  in  an  indirect  manner — for  example,  by  a  concussion  {con- 
cussion cataract).  To  this  category  belong  those  cataracts  which  have 
followed  a  lightning-stroke.  A  number  of  examples  are  recorded,  both 
double  and  single,  partial  and  complete.  In  addition  to  the  cataract, 
optic  neuritis,  optic  atrophy,  rupture  of  the  choroid,  iritis,  iridocyclitis, 
miosis,  mydriasis,  and  palsy  of  accommodation  have  been  observed. 
Cataract  may  also  be  caused  by  a  violent  electric  shock  and  apparently 
has  resulted  from  exposure  to  a; -rays,  while  being  used  in  the  treatment 
of  lupus  of  the  lid  (0.  Wilkinson). 

8.  Diseases  of  the  Eije. — Cataract  may  be  secondar}^  to  numerous 
acute  and  chronic  affections  of  the  ej-e — viz.,  iritis,  iridoc3"clitis, 
iridochoroiditis,  choroiditis,  detachment  of  the  retina,  glaucoma,  and  dis- 
eases of  the  cornea,  especialh'  sloughing  ulcers.  The  frequent  coexist- 
ence of  disturbance  of  the  choroidal  coat  and  incipient  cataract  has  led 
to  the  opinion  that  while  opacity  of  the  lens  (so-called  senile)  is  a  con- 
dition commonly  seen  in  advanced  life,  it  does  not,  in  all  probabihty, 
depend  upon  senile  changes,  but  upon  local  pathologic  states  involving 
the  nutrition  of  the  eve  itself. 


436  DISEASES    OF   THE    CRYSTALLINE    LENS 

9.  Accommodative  Strain. — Investigations  show  that  a  large  majority 
of  cataractous  eyes  are  hyperopia  and  astigmatic,  and  it  has  been 
stated  that  the  danger  of  cataract  is  increased,  where  the  astigmatism 
is  against  the  rule  and  remains  uncorrected.  The  evident  prophy- 
lactic measure  is  the  use  of  proper  glasses. 

The  etiology  of  cataract  is  by  no  means  always  clear,  and  often 
several  factors  are  necessary  to  explain  it;  sometimes  no  direct  cause 
can  be  assigned;  frecjuently  there  are  extra-ocular  causes  and  the 
cataract  results  from  nutritive  disturbances. 

The  following  additional  facts  in  regard  to  the  clinical  varieties 
deserve  attention: 

I.  Senile  Cataract  (Simple  Cataract;  Gray  Cataraci). — This,  repre- 
senting the  type  of  general  cataract  which  develops  after  the  fortieth 
year  of  hfe,  is  nuclear,  cortical,  or  mixed  in  its  origin.  It  may  not 
appear  before  the  sixtieth  year.  Its  course  from  incipience'  to  full 
maturity  has  been  described. 

The  color  usually  is  gray,  and  the  nucleus,  which  itself  does  not 
become  cataractous,  but  is  sclerosed,  may  be  recognized  b}'  its  yellowish 
or  brownish  hue  and  its  waxy  appearance. 

If  the  nucleus  is  small  and  the  surrounding  cortex  uniformly  white, 
the  cataract  is  comparatively  soft;  if  the  nucleus  is  large  and  the  color 
of  the  cataract  distinctly  gray,  yellowish,  or  brownish,  it  is  hard. 

Instead  of  a  gray  or  graj'ish-white  color,  the  cataract  may  be  yellow 
or  amber,  or  the  sclerosis  of  the  nucleus  extends  to  the  cortical  sub- 
stance, so  that  the  whole  lens  is  brownish  and  the  pupil  black  (black 
cataract).  Occasionally  clwlesterin  crystals  may  be  found  in  cataracts, 
not  only  in  the  senile,  but  also  in  the  juvenile  variety-. 

Senile  cataract  generall}'  is  bilateral,  one  eye  being  more  affected 
than  its  fellow;  but  a  cataract  may  attain  maturitj'in  one  e3'e  before 
the  other  lens  is  affcctcHl  (unilateral  cataract). 

II.  Juvenile  cataract  is  a  term  descriptive  of  those  oixicities  of  the 
lens  which  occur  before  the  fortieth  year  of  life.  To  such  cataracts  the 
name  presenile  is  also  given  (Nettleship). 

In  forms  of  cataract  developed  in  early  life  the  cv  idence  of  the 
influence  of  heredity  is  often  strong. 

General  cataracts  in  3'oung  i)ersons  (complete  cataract  of  youny 
people)  may  ari.se  without  known  cause  or  from  one  or  other  of  the 
causes  already  recorded.  These  are  bluish  white,  often  have  a  sheen 
like  ])earl,  and  are  soft. 

III.  Congenital  Cataract. — This  may  ajjjjcar  as  a  complete*  or 
])artial  o]).i(ity  of  tli<'  lens.  In  the  complete  form  the  lens  usually  is 
white  or  bluish-white  in  eoh)i-,  denselj'  opaque,  and  soft.  The  eye 
may  be  otheiwise  lieiiilhy,  oi-  there  may  be  changes  in  the  choroid, 
I'etina,  o))tic  nerve  (congenital  amblyopia),  and  sometimes  vices  of 
conforniat ion,  as  coh)bonia,  microi)hthahnos.  anil  hy(h()])hlhalinos. 
Distinbances  of  nutrition  during  inlra-uterine  hfe,  elianges  in  the 
choroid,  arrest  of  development,  consanguinity  of  i)arenls,  ,in(l  heredit>' 
have  been  in\'oke(l  to  explain  its  existence. 


CATARACT  437 

There  are  several  varieties  of  partial  congenital  cataract: 
(a)  Zonular,  lamellar,  or  perinuclear  cataract  appears,  as  its  name 
implies,  in  the  form  of  an  opaque  layer  sm-rounding  the  clear,  but  some- 
times cloudy,  center  of  the  lens,  and  is  the  most  frequent  form  of  partial 
congenital  cataract.  On  the  surface  streaks  of  opacity  are  often 
evident,  which  may  project  into  the  clear  cortex  and  are  called  "riders." 
Usually  it  is  double,  but  may  be  unilateral,  and  is  either  congenital  or 
forms  in  early  infanc3^  The  cataract  is  stationar}'  in  most  instances, 
but  occasionally  becomes  complete. 

If  the  center  of  the  pupil  is  examined,  a  reddish  point  surrounded 
by  a  grajdsh  halo  will  be  observed.  When  the  pupil  is  dilated  with 
atropin  and  examined  with  the  ophthahnoscopic  mirror,  the  central 
dark  zone  will  be  apparent,  surrounded  by  a  reddish  circle,  due 
to  the  reflection  from  the  fundus 
passing  through  the  peripheral 
part  of  the  lens,  which  remains 
clear.  With  obhque  light  the 
appearances  may  be  as  in  Fig. 
196.  A  rare  type  is  several  zones 
of  opacity  separated  by  zones  of 
transparency.  Patients  with 
zonular  cataract  act  like  mj'opes, 

and  the  refraction  of  the  eye  maj'    

be    mj'opic.      Macular    changes  I      '        ~  ~     ~ 

,    .    p  .  riG.   196. — Zonular  cataract  (after  Spicer). 

are  not  mfrequent. 

The  cause  of  lamellar  cataract  is  not  certain!}'  known.  In  the 
congenital  variety  it  is  probably  due  to  some  developmental  defect;  in 
the  variety  arising  in  early  infancy  some  fault  in  nutrition  has  occurred. 
Most  often  the  subjects  are  rachitic,  and  present  the  teeth  and  cranial 
asymmetry  pecuhar  to  this  affection.  Peters  considers  tetany  a  more 
common  cause  than  rachitis,  and  Hesse  and  Phelps  emphasize  the  fre- 
quent association  of  zonular  cataract  and  tetany- — both  are  attributed 
to  the  faulty  calcium  metabolism  depending  upon  parath^Toid  insuffi- 
ciency. A  historj^  of  convulsions  is  common,  and  dental  defects, 
which  are  present  in  the  form  of  lines,  furrows,  or  terraces,  may  lie 
transversely  across  the  incisors  or  canines.  Anatomically,  lamellar 
cataract  consists  of  a  narrow  zone  of  degenerative  change  in  the  lens- 
fibers,  situated  between  the  nuclear  and  cortical  areas  (Lawford). 

Cataract  may  develop  in  later  life,  that  is,  between  the  ages  of 
twent}^  and  fifty,  in  persons  who  suffer  from  tetanic  spasms.  These 
patients  may  also  suffer  from  loss  of  hair,  necrosis  of  the  nails,  and 
chronic  skin  eruption.  To  such  cataracts  the  name  tetany  cataract 
has  been  given,  and  they  are  apparently  due  to  a  toxin  which  affects 
epithelial  structure  (E.  T.  Collins)  (see  also  page  434). 

(6)  Central  cataract  (central  lental  cataract)  consists  of  a  white 
opacity  in  the  central  part  of  the  lens,  due  probably  to  faulty  develop- 
ment at  an  early  stage  of  intra-uterine  existence.  Sometimes  vision 
is  surprisingl}'  good;   at   other  times  it   ma}^  be   poor,  and  defects 


438 


DISEASES    OF   THE    CRYSTALLINE    LENS 


of   development    in    the   eye   may  be    present  and  nystagmus  may 
develop. 

(c)  Pyramided  Cataract. — This  is  also  known  as  anterior  capsular  or 
polar  cataract,  and  consists  of  a  small,  well-defined,  pyramidal-shaped 
or  circular  opacity  due  to  hATierplasia  of  the  capsular  epithelium  and 
degeneration  of  tiie  lens-fibers  in  that  position.  It  proljably  arises  in 
consequence  of  contact  of  the  lens  and  cornea  in  fetal  life,  which  causes 
an  arrest  of  osmosis  of  nutritional  fluid  (E.  T.  ColUns).  !Mules  sug- 
gested that  these  cataracts  may  be  cretified  remains  of  the  pupillary 
membrane. 

At  the  posterior  pole  of  the  lens  an  opacity  similar  to  the  one 
described  may  be  found,  known  as  a  posterior  polar  or  pyramidal  con- 
genital cataract.     It  is  caused  by  vestijjial  remains  of  the  hyaloid  arterj' 

at  its  lenticular  attachment, 
or  persistence  of  the  part  of 
t  he  posterior  vascular  sheath 
of  the  lens,  a  n  d ,.  s  t  r  i  c  1 1  y 
speaking,  is  not  a  true  cata- 
ract, that  is,  the  changes  are 
not  in  the  lens.  These 
opacities  are  sometimes  sep- 
arated into  those  which  lie 
beneath  the  capsule  and 
those  which  exist  upon  its 
surface.  A  small  dot-like 
opacity  of  this  origin,  and 
which  does  not  disturb  vision,  is  quite  common.  S.  L.  Ziegler  and 
J.  M.  Griscom  have  published  a  report  of  hereditary  ])osterior  polar 
cataract  (their  two  patients  having  had  ''double  posterior  i)olar  catar- 
act of  the  hereditary  t3'pc;"  there  is  no  description  of  the  ajipearance 
of  the  cataracts).  A  study  of  the  pedigrees  which  they  present  shows 
there  were  64  members  in  four  generations,  of  whom  24  had  congenital 
cataracts.  The  relative  percentage  of  females  affecteil  was  sligiitly 
higher  than  that  of  males.  In  no  case  did  normal  parents  ])roduce 
affected  children. 

(f/)  Punctate  cataract  is  an  unusual  form  ol"  congenital  lenticular 
change  in  which  the  opacities  present  themselves  in  the  form  of  more 
or  less  fine  })oin(s,  oc(!U])ying  the  center  of  the  ]mi)illary  space.  These 
points  or  dots,  however,  may  extend  througli  the  anterior  cortc^x  to 
the  periphery  of  the  lens,  and.  as  in  HoUoway's  case  have  a  i)luish  tint 
and  be  present  in  several  members  of  the  same  family.  l'\)rms  of 
punctate  cataract  occur  iVeciuenlly  in  Mongolian  idiots,  well  studied  by 
Pearce,  Rankin  and  Oniiond.  The  dot-like  lesions  ma>'  be  and  prolj- 
ably are  congenital;  other  types  occur  in  older  subjects  -  antcM-ior  and 
posterior  o])acity.  \V.  J\I.  \an  der  Sclieer  louiid'J'J  among  .'iti  i)atients. 
The  cataract  remains  stationary  for  a  long  time.  It  is  not  very  un- 
common to  find  in  lic.-illhy  adults  punctate  lesions  in  the  le?is,  th;it  is. 
in   the  anterior  cortex   and   in    two   patients  under  llie  author's  care 


Fig.   197. 


-Anterior  polar  cataract  (after  Nettle- 
ship). 


CATARACT 


439 


the  lesions  are  disposed  in  the  periphery  as  ahnost  equidistant  spots, 
which  doubtless  are  congenital  in  origin,  which  do  not  increase  and  do 
not  interfere  with  visual  acuteness. 

(e)  Fusiform  cataract  is  a  rare  variety  characterized  by  an  opaque 
stripe  passing  from  the  anterior  to  the  posterior  pole  of  the  lens,  some- 


FiG.  198.- 


-Congenital  cataract  of  peculiar  type. 
Hospital.) 


(From  a  patient  in  the  University 


times  with  offshoots,  disposed  like  coral  branches.  It  may  be  com- 
bined with  zonular  cataract.  It  is  also  known  as  axial  or  corallijorm 
cataract,  and  is  prone  to  occur  in  families.  Nettleship's  hst  contains 
the  record  of  one  family  in  which  thirty  members,  in  four  generations, 


Fig. 


?nital. 


lii    star-shaped   opacities  of  the   cr^  s'allinc   lens,   probably 
(From  a  patient  in  the  University  Hospital.; 


were  known  to  be  affected.  Microscopically,  a  lens  with  coralhform 
cataract  shows  numerous  crystals  most  marked  at  the  anterior  and 
posterior  poles;  the  surrounding  lens  substance  exhibits  vacuolization 
and  fragmentation.     The  nature  of  the  crystals  is  not  definitely  known; 


440 


DISEASES    OF   THE    CRYSTALLINE    LENS 


they  prohahly  iciJicscnt  crystallized  Ions  proteins  (Verhoeff).  Nettle- 
ship  and  O^ilvic  liave  described  a  peculiar  form  of  congenital  family 
cataract  in  which  a  disk  of  opacity  (discord  or  "Coppock"  cataract), 
"consisting  of  a  single  layer,  always  thin,  but  varying  in  transparency, 
is  situated  })ehind  the  nucleus,  but  well  in  front  of  the  posterior  capsule." 
A  similar  if  not  identical  form  of  family  cataract  has  been  reported 
in  this  country  In'  Burton  Chance.  Discoid  and  lamellar  cataracts 
are  essentially  similar,  the  former  being  smaller  and  more  deeply 
palced  due  to  backward  displacement  of  the  nucleus.  Disk-shaped 
opacities  behind  flu^  nucleus,  often  hereditary,  are  also  termed"  Dome's 
cataract." 

IV.  Complicated  or  Secondary  Cataract. — This  may  be  complete 
and  arise  in  consequence  of  the  various  diseases  of  the  eye  enumerated 
on  page  435.  In  iritis,  for  example,  fibrinous  exudations  are  attached 
to  the  lens-capsule,  contraction  occurs,  the  capsule  is  disturbed  in  its 
relation  to  the  underlying  lens-fibers,  which  are  separated,  and  cataract 
forms.  If  this  process  is  a  limited  one,  the  lenticular  opacity  may 
remain  circumscribed.  It  may  also  be  incomplete,  and  appears  in 
the  following  varieties: 

(«)  Anterior  Polar  Cataract. — In  addition  to  the  congenital  variety 
of  this  opacity  there  is  an  ac(iuired  type,  which  arises  in  consecpience 
of  a  perforating  ulcer  of  the  cornea — for  example,  in  ophthalmia  neo- 
natorum (see  page  211).  In  infants'  eyes  it  may  follow  ulceration  of 
the  cornea  without  perforation. 

(b)  Posterior  polar  cata- 
ract, as  a  congenital  variety, 
has  been  described.  As  be- 
fore noted,  being  outside  of 
the  lens  system  it  is  not  a 
cataract  in  the  true  sense  of 
that  term.  In  some  cases, 
h()wev(>r,  a  jJostcM'ior  polar 
cataract,  that  is,  one  on  the 
posterior  surface  of  the  i)OS- 
tcrior  capsule  of  the  lens,  is 
combined  with  an  opacity  in 
the  lens  clos(>  biMieatli  tiu^ 
capsule. 

(c)  Anterior  and  Posterior  Cortietd  Cataract.  This  form  (tf  cataract, 
usually  ill  I  lie  ])oslcrior  (^oitcx  and  generally  star-shap(>d  or  in  the 
form  of  a  ro.sette,  is  a  common  variety  of  comi)lica(ed  cataract,  seen  in 
liigii  myoj)ia,  vitreousdi.sea.se,  dis.seminated  choroiditis, and  i)igmentary 
dcgciicr.ation  of  the  retina.  It  may  remain  stationary  for  a  long  time, 
disturlMug  vision  in  ])ro|)ortion  to  its  density,  or  it  may  i)rogr(>ss  and 
become  complete.  A  siiiiil.ir  ;ii)j(e;ir.uice  in  I  lie  anterior  cortex  ol  the 
lens  is  sometimes  visible;  occ;isioii;dl>'  the  opacity  exists  in  both  i)osi- 
tions  at  the  same  time.  When  either  aiitei-ioi-  or  ])osterior  cortical 
(Mitaract    in    these   circiiiiisl;iiices    becomes    tot;il  it  s  e\t  raii  i(»n  is  indi- 


Fi(j.  200.-  Posterior  rtjrticul  cataract  seen  !>>' 
transmitted  li^ht  (from  a  case  of  pi>.'nieiitaiy 
dogciieratioii  of  the  retina). 


CATARACT  441 

cated,  but  the  prognosis  is  not  as  favorable  as  it  otherwise  would  be 
because  the}'  are  complicated  with  the  ocular  diseases  which  have  been 
mentioned. 

A  form  of  complicated  family  cataract  has  been  described  by  Purt- 
scher  and  by  Zentmayer.  It  occurs  about  the  age  of  thirty  in  eyes 
with  thin,  bluish-white  scleras,  tremulous  gray-brown  irides,  deep 
anterior  chambers,  contracted  pupils,  and  a  tendency  to  glaucoma  after 
operative  interference. 

V.  Traumatic  Cataract. — This  is  caused  by  direct  injury  to  the  lens 
by  some  penetrating  substance  which  lacerates  the  capsule  and  then 
permits  the  entrance  of  the  aqueous  humor.  (See  also  page  435.)  The 
lens  substance  swells  up,  becomes  opaque,  and  some  of  it  may  escape 
into  the  anterior  chamber.  Absorption  takes  place  in  about  six  weeks. 
This  course  represents  the  most  favorable  outcome  of  such  an  accident. 
In  other  cases  there  may  be  iritis,  cyclitis,  and  secondary  glaucoma, 
owing  to  swelling  of  the  lens  and  elaboration  of  lens-toxins. 

Instead  of  going  on  to  complete  opacity,  an  injured  lens,  in  some 
instances,  presents  a  limited  opacity,  which  remains  stationary;  in 
other  instances  this  disappears,  and  in  still  others  there  is  slow  advance 
of  the  opacity. 

The  opacity  was  explained  by  ^^larcus  Gunn  bj^  the  action  of  the 
sodium  chlorid  of  the  aqueous  humor  upon  the  globulin  of  the  lens 
substance.  This  explanation,  according  to  C.  A.  Clapp,  is  inconsistent 
with  chemical  facts.  He  believes  that  when  "the  lens-fibers  are 
broken  up  they  undergo  autolytic  changes." 

A  more  indirect  mechanism  of  traumatic  cataract  is  concussion 
(concussion  cataract) — a  blow  upon  the  eye  causing  a  slight  rupture  of 
the  anterior  or  posterior  capsule,  followed  bj'  opacit}',  which  may  be- 
come general  or  retain  a  limited  size  for  a  long  time.  According  to 
Nettleship,  absorption  of  a  complete  concussion  cataract  is  more  un- 
common than  where  the  lenticular  opacity  has  followed  a  direct 
trauma,  although  the  lens  may  gradually  shrink  in  size. 

A  ring-shaped  opacity  may  appear  on  the  surface  of  the  lens  after 
contusion  of  the  eye,  generally  in  young  eyes.  This  is  a  circular 
opacity,  3  to  4  mm.  in  diameter,  concentric  to  the  margin  of  the 
pupil,  and  of  a  brownish  color.  The  lesion  is  sometimes  called 
Vossius'  ring,  or  contusion-lesion  oj  the  lens  (Caspar).  Vossius  ascribes 
the  lesion  to  pigment  adherent  to  the  capsule  or  to  disturbance  of  the 
epithelium.  It  is,  as  it  were,  a  cast  of  the  iris  margin  and  its  pigment 
on  the  capsule.  This  explanation  is  not,  however,  accepted  by  all 
observers.  In  several  eyes  studied  by  the  author  the  lesion  disappeared 
within  a  few  weeks  after  the  injury. 

VI.  After-cataract. — This  name  has  been  applied  to  those  changes 
which  occur  in  the  capsule  of  the  lens  remaining  after  the  extraction  of 
cataract.     It  is  usually  called  secondary  cataract. 

These  changes  may  depend  on  proliferation  and  thickening  of  the 
capsular  epithelium;  on  agglutination  of  the  two  layers  of  the  capsule, 
the  anterior  part  being  so  folded  over  that  it  has  retained  cortical  mate- 


442  DISEASES    OF   THE    CRYSTALLINE    LENS 

rial,  which  has  thus  been  shut  off  from  the  dissolving  action  of  the 
aqueous  and  remains  as  a  membranous  opacity;  or  upon  new-formed 
tissue  between  the  capsule  layers  or  thickened  elements  from  the 
anterior  part  of  the  vitreous.  If  there  has  been  postoperative  reaction, 
fibrinous  exudation  from  the  iris  adds  to  the  opacity.  (Consult  Fig. 
382.)  The  name,  that  is,  secondar}-  cataract,  has  also  been  given  to 
the  dense  white  membrane  {membranmis  cataract)  which  is  composed 
of  deposits  of  lymph,  and  fibrinous  and  plastic  exudation,  and  to  which 
the  iris  and  even  the  ciliary  processes  are  adherent,  and  which  follows 
postoperative  iridocyclitis. 

VII.  Capsular  Cataract. — The  name  capsular  cataract  is  applied  to 
thickenings  and  proliferations  of  the  capsular  epithelium,  and  some- 
times to  subcapsular  degeneration  of  the  lens-fibers,  which  may  be 
congenital,  may  follow  inflammatory  processes  of  the  eye  (corneal 
ulcer),  and  maj^  occur  in  connection  with  other  degenerations  in  over- 
ripe cataract. 

VIII.  Capsulolenticular  cataract  is  the  name  applied  to  opacity  of 
the  lens  associated  with  thickening  of  the  surrounding  capsule,  most 
commonly  in  the  center  of  its  anterior  portion. 

Prognosis. — Incipient  cataract  in  the  form  of  striae  in  the  anterior 
cortex  need  not  doom  the  patient  to  rapid  deterioration  of  sight,  be- 
cause the  existing  vision  is  often  maintained  for  long  periods  of  time. 
Spontaneous  disappearance  of  senile  cataract  has  been  reported.  Ac- 
cording to  Pyle,  this  may  occur  on  account  of  ruptur(>d  caiisule.  dis- 
location, or  deg(>nerative  changes;  rarely  this  j^henomenon  has  been 
observed,  although  the  history  of  such  an  etiologic  relationship  could 
not  be  obtained. 

Operation  is  preferably  deferred  until  the  cataract  is  ripe.  The 
surgeon  must  ascertain  whether  the  eye  itself  is  in  a  healthy  condition 
by  attention  to  the  following  considerations: 

(a)  The  probable  condition  of  the  interior  of  the  eye,  if  no  data  of 
ophthalmoscopic  examinations  during  the  incipiency  of  the  cataract 
are  at  hand.     This  is  ascertained  as  follows: 

Place  the  ))atient  Ix'fore  a  lighted  candl(>  or  a  small  elect ricaily 
illuminated  bulb  about  4  meters  distant — the  light  should  be  distinctly 
recognized.  This  gives  evidence  that  the  macular  region  is  free  from 
extensive  disease,  but  does  not  exclude  a  small  lesion.  Next  cause 
the  eye  under  examination  to  fix  the  light  attentively,  and  move  a 
second  lighted  candle  or  electric  bulb  radially  through  the  field  of 
vision.  The  light  should  be  recognized  as  soon  as  the  rays  strik(»  the 
edge  of  the  cornea,  and  the  patient  should  be  able  to  indicate  the  direc- 
tion in  which  it  is  coming.  Tims  the  "light-field."  or  th(>  "projection 
of  light,"  is  tested,  and,  it"  the  answers  have  Ix'cii  ;iccuiat(',  "projection 
of  light  is  good  in  all  parts  of  the  field.'' 

If  the  patient  fails  to  appreciate  the  caiMJlc-llamf  in  aii\  portion  of 
the  field,  coarse  changes  may  be  susi)ecte(i  <•.  y.,  extiMisivc  choroiditis, 
detachnienf  of  the  retina,  glaucoma,  etc.;  but  it  is  not  possible  to  detect 
a  small  ai"e;i  ol  cmlial  choroiditis  by  this  means  isc*'  also  page  iVSO). 


CATARACT  443 

The  macular  region  should  be  investigated  by  requiring  the  patient 
to  note  the  separation  of  two  small  centrally  placed  flames,  or  by 
causing  him  to  look  at  the  light  through  a  small  aperture  in  the  center 
of  a  disk.  Fluid  vitreous,  indicated  by  tremulousness  of  the  iris,  is  an 
unfavorable  sign.  Should  there  be  no  light-perception,  the  cataract  is 
an  unsuitable  one  for  operation  except  that  in  certain  circumstances  its 
extraction  is  justified  in  order  to  improve  the  patient's  appearance. 

(b)  The  Probable- Condition  of  the  Refraction.- — It  may  be  impossible 
to  ascertain  this  unless  some  record  is  at  hand  of  an  examination  when 
the  media  were  still  clear.  Some  idea  of  the  refraction  is  obtainable  by 
examining  the  glasses  which  the  patient  may  have  used  during  his 
reading  days.  High  myopia  renders  the  prognosis  less  favorable;  in- 
deed, the  vision  after  operation  in  myopic  cases,  other  things  being 
equal,  is  not  so  good  as  that  of  hyperopes. 

(c)  The  Mobility  of  the  Iris;  Its  Reaction  to  a  Mydriatic. — This 
should  be  prompt  and  normal.  Failure  of  iris  reaction  in  either  case 
msiy  indicate  imperfect  conductive  power  in  the  optic  nerve,  or  atrophy 
or  other  change  in  the  iris. 

(d)  The  Age  and  General  Condition  of  the  Patient. — Advanced  age 
alone  does  not  militate,  as  much  as  it  would  seem  likely  to  do,  against 
successful  cataract  extraction.  So,  too,  the  extraction  of  diabetic 
cataract  is  often  followed  by  good  results;  and  even  the  presence  of 
chronic  Bright's  disease,  while  a  complicating  circumstance,  does  not 
forbid  the  operation.  Great  feebleness,  dementia  likely  to  become 
worse  with  confinement,  nasopharyngitis,  advanced  arteriosclerosis, 
eczema,  enlarged  prostate  and  cj^stitis,  and  chronic  bronchitis  are  un- 
favorable conditions.  According  to  Hansell,  syphilis  should  be  re- 
garded as  a  dangerous  complication. 

(e)  The  Condition  of  the  Area  of  Future  Operation  and  of  Its  Sur- 
roundings.— Disease  of  the  lacrimonasal  channels,  trachoma,  chronic 
conjunctivitis,  and  blepharitis  contraindicate  cataract  extraction  be- 
cause the  wound  is  almost  certain  to  become  infected  by  the  unhealthy 
discharges.  In  such  circumstances  a  line  of  treatment  later  described 
must  be  instituted  before  operation.  A  matter  of  importance,  not 
always  attended  to,  is  the  state  of  the  rhinopharynx.  This  should  be 
reasonably  healthy  to  secure  the  highest  type  of  success.  The  teeth 
and  tonsils  should  be  carefully  examined  for  areas  of  focal  infection. 
Eczema  of  the  face  or  other  regions  of  the  body  is  a  source  of  danger. 
Prior  to  cataract  extraction  a  careful  bacteriologic  examination  of  the 
conjunctiva  is  important. 

(/)  The  Type  and  Condition  of  the  Cataract. — In  making  a  prognosis 
the  size  of  the  nucleus  and  its  position,  the  probable  consistence  of  the 
cortex,  the  primary  or  secondary  nature  of  the  cataract,  and  its  stage 
of  maturity  must  be  considered.  Certain  conditions  (amblyopia) 
influence  the  prognosis  in  complete  congenital  cataract,  and  in  the 
partial  varieties,  like  the  lamellar  form,  the  eye  may  be  defective  in 
construction.  In  traumatic  cataract  the  extent  of  injury  to  parts 
other  than  the  lens  must  be  regarded. 


444  DISEASES    OF   THE    CRYSTALLINE    LEXS 

Treatment. — This  may  be  divided  into  the  treatment  of  immature 
and  of  tnaturc  cataract. 

Drugs  do  not  exist  which  can  dissolve  a  growing  cataract,  and  the 
use  of  electricity,  which  has  been  recommended,  is  of  no  value.  Light 
massage  of  the  eyeball  after  the  instillation  of  a  mixture  of  glycerin 
and  boric  acid  solution  has  been  coniraendod  (Kalish);  or  a  1  percent, 
solution  of  iodid  of  sodium  or  a  3^2  per  cent,  solution  of  iodid  of  po- 
tassium may  be  similarly  employed.  This  procedure  in  certain  ca.ses 
seems  to  afiford  a  certain  amount  of  relief  probably  because  of  a  stimu- 
lating effect  on  the  anterior  circulation  of  the  eye. 

1.  The  refraction  should  be  carefully  tested  and  that  glass  ordered 
which  gives  the  most  accurate  vision.  It  may  be  necessary  to  make 
frequent  changes  in  the  correcting  lenses  to  conform  with  the  altera- 
tions in  refraction  brought  about  by  alteration  in  the  lens.  Correction 
of  lenticular  myopia  usually  markedly  improves  the  distant  vision  (see 
page  429). 

2.  Congestion  of  the  choroidal  coat  may  be  relieved  by  the  exhibi- 
tion of  certain  alteratives,  among  which  the  iodids  of  sodium  and  po- 
tassium and  syrup  of  hydriodic  acid  are  the  most  suitable.  The 
iodids  may  be  combined  with  small  doses  of  bromid  of  potassium  or 
broraid  of  sodium.  Binioditl  of  mercury  has  also  been  tried.  Sub- 
conjunctival injections  of  iodid  of  potassium  have  been  recommended 
(Badal,  von  Pflugh) ;  of  their  value  the  author  has  no  knowledge. 
Dor  advocates  the  treatment  of  cataract  locally  with  a  solution  com- 
posed of  4  grams  of  desiccated  sodium  iodid,  4  grams  of  crystallized 
calcium  chlorid,  dissolved  in  500  grams  of  distilled  water.  The  solu- 
tion should  be  applied  for  half  an  hour  a  day  be  means  of  a  glass  eye- 
bath.  Some  observers  report  favorable  results  from  the  i)ersistent  use 
of  dionin  in  solutions  of  gradually  ascending  strength  and  favorable 
results  have  been  reported;  the  remedy  should  receive  full  trial  in  this 
regard.  Col.  Henry  Smith  strongly  recommends  subconjunctival 
injections  of  cyanid  of  mercury  (1  :4000-G000).  The  treatment  of 
incipient  cataract  by  radium  has  been  advocated  by  Martin]  Coiien 
and  Isaac  Levin. ^  The  moderate  use  of  the  eyes  may  be  permitted 
without  danger  of  hastening  the  process  of  maturation.  If  the  patient 
suffers  from  diabetes,  nephritis,  lithemia,  or  arteriosclerosis,  suitable 
dietetic  and  medicinal  measures  should  be  employed.  Drinking  water 
freely  is  advised  by  Edward  .hickson. 

3.  Often  comfort  may  be  given  and  vision  improved  by  keeping  the 
pupil  dilated  with  a  weak  mydriatic  (if  the  opacity  is  central).  Tinted 
lenses,  which  correct  any  existing  refractive  error,  should  be  worn.  In 
other  cases  a  miotics  is  useful. 

If  the  vision  of  eyes  suff."iiiig  from  cataract  of  the  nuclear  type  is 
improved  by  mydriasis,  this  has  been  given  as  an  imlication  for  optical 
iridecloniij,  but  is  not  a  sufhcient  one  unless  the  patient  finds  by  observa- 
tion that  the  increased  visual  acuteness,  as  jnoted  by  test-type  ex- 
amination, is  also  advantageous  in  pui'suing  his  ordinary  occupation. 
'  Tniii.SHotioii.s,  S('<!ti()ii  of  ()|)litli.iliiutl((j;\  .  Amcr.  .Mrd.  .\s.soc.,  191U. 


CATARACT  445 

Artificial  Ripening. — The  exceeding  slowness  with  which  a  senile 
cataract  may  progress  often  leaves  the  patient  in  a  state  of  semiblind- 
ness.  To  remedy  this,  several  methods  have  been  proposed  for  hasten- 
ing the  process  of  ripening. 

Simple  division  of  the  anterior  capsule;  division  combined  with 
iridectomy  (Mooren) ;  division  and  external  massage  (Rohmer) ;  iridec- 
tomy and  triturating  the  lens-fibers  by  rubbing  the  cornea  over  the 
coloboma  with  a  horn  spoon  (Forster's  method);  paracentesis  of  the 
cornea,  and  internal  massage  directly  on  the  anterior  capsule  with  a 
small  spatula  (Sasso  and  Ricaldi  and  B.  Bettmann,  of  Chicago);  and 
simple  paracentesis  of  the  cornea  with  external  massage  (T.  R.  Pooley, 
of  New  York,  and  J.  A.  White,  of  Richmond,  an  operation  practised  by 
the  latter  surgeon  with  much  success). 

A  discission,  after  the  manner  of  Graefe.  carried  deep  into  the  lens 
substance,  was  recommended  by  Schweigger  as  the  only  satisfactory 
method,  especialh^  before  the  fortieth  j^ear;  and  a  preliminary  capsv- 
lotomy  has  been  advised  and  practised  by  Homer  E.  Smith  (see  page 
745).  He  has  reported  excellent  results,  as  have  other  surgeons  who 
have  followed  his  method. 

Treatment  of  Immature  Cataract. — Some  operators  of  extensive 
experience  hold  that  the  usual  criteria  of  ripeness  are  erroneous  in  that 
period  when  accommodation  is  annulled  bj'  phj^siologic  changes  in  the 
lens — that  is,  about  the  sixtieth  year — and  the  lens  may  be  extracted 
safely  even  if  it  is  in  part  unclouded.  It  may  also  be  done  successfully 
at  an  earlier  age. 

Many  operators,  following  jNIcKeown's  advice,  after  the  extraction 
of  immature  cataract  resort  to  intracapsular  irrigation  and  wash  out 
tenacious  cortical  material  with  a  suitabh'  warmed  physiologic  salt 
solution.  Indeed,  irrigation  of  the  anterior  chamber  forms  part  of  the 
technic  of  all  cataract  operations  in  the  hands  of  some  surgeons.  Suit- 
able irrigation  apparatus  has  been  designed  by  jMcKeown  and  by  J.  A. 
Lippincott,  but  a  flat  tipped  glass  tube  to  which  is  attached  a  rather 
large  rubber  bulb  answers  the  purpose  eciually  well. 

If  the  unripe  material  is  not  removed  it  may  swell  up  and  cause 
iritis,  probably  because  of  development  and  liberation  of  toxins. 
Therefore  the  safest  plan  is  to  wait  for  maturity;  but  if  this  is  impos- 
sible or  very  undesirable  or  the  patient  is  unwilling  to  wait  until  the 
cataract  is  mature,  the  author  has  been  in  the  habit  of  extracting  an 
unripe  cataract  after  preliminary  iridectomy  in  preference  to  per- 
forming a  ripening  operation  and  if  necessarj'-  has  employed  irrigation 
with  normal  saline  solution  to  get  rid  of  cortical  remnants  which 
could  not  otherwise  be  satisfactorily  expelled.  In  a  few  instances  he 
has  practised  deep  discission  or  preliminary  capsulotomy. 

According  to  Colonel  Henry  Smith,  Derrick  Vail,  W.  A.  Fisher, 
and  a  few  other  surgeons,  the  best  means  of  managing  immature 
cataract  is  its  extraction  in  the  capsule  by  the  so-called  Indian  or  Smith 
method  (see  page  735).  The  stage  of  immaturity  at  which  Smith 
advocates  the  extraction  of  immature  cataract  in  the  capsule  is  where 


446  DISEASES    OF   THE    CRYSTALLINE    LENS 

the  opacity  has  progressed  so  far  as  to  unfit  the  patient  for  the  per- 
formance of  his  ordinary  (kities.  With  this  operation  in  this  regard 
the  author  has  had  no  experience.  Inunature  cataracts  can  be  re- 
moved ('(luallv  well  l)v  other  methods  of  intracapsular  extraction  (page 
738). 

Treatment  of  Mature  and  Complete  Cataract. — Mature  cataract 
requires  an  operation  for  its  removal,  differing  according  to  the  age 
of  the  patient  and  the  consistency  of  the  cataract. 

Hard  cataracts,  or  those  which  occur  after  the  fortieth  year,  are 
suitabl}'  removed  either  by — (a)  simple  extraction  (extraction  without 
iridectomy),  (b)  combined  extraction  (extraction  with  iridectomy),  or 
extraction  after  preliminarj'^  iridectomy,  (c)  intracapsular  extraction 
(extraction  in  the  capsule). 

Soft  cataracts,  or  those  which  occur  before  the  thirtieth  year,  are 
suitably  removed  by — (a)  linear  extraction;  (6)  the  needle  operation, 
or  that  of  solution  by  discission;  and  (c)  the  suction  method.  A  soft 
cataract  before  the  twenty-fifth  year  may  be  removed  through  a  linear 
incision  into  the  cornea,  and  a  semifluid  one  by  suction.'  Complete 
cataract  of  young  people  and  complete  congenital  cataract  are  gener- 
ally removed  by  discission,  the  latter  variety  of  cataract  being  ready  for 
operation  after  the  completion  of  dentition. 

According  to  E.  Treacher  Collins,  a  child  should  be  ten  months  old 
before  operating  for  congenital  cataract.  If  the  pupil  is  small  and  does 
not  dilate  with  atropin,  an  iridectomy  may  first  be  necessary.  In  so- 
called  disk-shaped  cataract,  that  is,  where  an  anterior  polar  one  is  set 
in  a  ring  of  clear  or  partially  clear  lens  substance,  an  attempt  should 
be  made  to  dislocate  it  with  a  needle  and  let  it  fall  into  the  anterior 
chamb(M-. 

Treatment  of  Partial  Congenital  Cataracts. — Central,  Icntal,  and 
zonular  cataracts  are  treated  by  iridectomy  or  by  discission.  The 
former  procedure  is  better  if,  after  dilatation  with  a  mydriatic,  there 
is  sufficient  improvement  in  vision  to  justify  the  manufacture  of  a  new 
pupil  or  glasses  do  not  improve  vision.  This  should  be  made  opposite 
to  the  clearest  part  of  the  lens.  If  this  does  not  prove  satisfactory,  the 
lens  may  be  needled  oi-,  finally,  the  entire  lens  may  be  extracted  (see 
page  724). 

Pyramidal,  punctate,  and  fusiform  cataracts  are  not  generally 
amenable  to  ojierative  treatment.  Discission  or  one  of  its  substitutes 
is  tlie  method  of  operating  applied  to  after-cataracts.  Sometimes 
an  opacity  of  the  hyaloid  membranes  is  noticeal)le  after  cataract  ex- 
traction, whicii  J-'Jnk  calls  hyaloid  cataract,  and  Ziegler  has  describeil 
an  adventitious  hyaloid  membrane  after  cataract  extraction  or  in  any 
case  of  aphakia  where  th(>  vitreous  has  been  e\|)osed  to  tlu^  action  of 
the  aciueous. 

lOxtraelion  of  unilateral  cataract  will  not  usu;iliy  give  tlie  patient  in- 
creased visual  acnteness  because,  owing  to  the  ine<iuality  of  refraetion, 
the  eyes  will  not  work  together.  'I'lie  operation  nia\-  be  performed 
(simple  extraction)  for  cosmetic  reasons,  and  sliouM  Ite  peifornied  to 


CATARACT  447 

avoid  overmaturity  in  the  opaque  lens,  and  to  improve  the  field  of 
vision  upon  the  affected  side.  If  there  is  divergence,  a  subsequent 
tenotomy  of  the  externus  or  advancement  of  the  internus  may  be 
necessary. 

The  technic  of  performing  the  various  methods  of  cataract 
extraction,  the  dangers  and  accidents,  will  be  described  on  pages 
729-738. 

After  a  successful  extraction  or  solution,  and  after  sufficient  time 
has  elapsed  to  secure  firm  healing,  a  suitable  pair  of  lenses  should  be  ad- 
justed— one  for  distant  vision  and  one  for  reading. 

Removal  of  the  crystalline  lens  produces  the  condition  technically 
spoken  of  as  aphakia,  and  causes  a  high  degree  of  hyperopia,  in  the 
emmetropic  eye  corresponding  to  about  11  D.  The  degree  of  hypero- 
pia will  be  diminished  if  the  previous  refraction  has  been  myopic, 
and  it  is  possible  to  produce  emmetropia  provided  the  former  near- 
sightedness has  been  of  such  degree  that  the  removal  of  the  lens 
exactly  neutralizes  it. 

In  ordinary  circumstances  the  correcting  lens  for  distant  vision 
is  about  +10  D.  For  reading  and  similar  occupation  a  lens  having 
a  focal  distance  of  25  to  33  cm.  is  added  to  the  distance  glass. 

In  addition  to  the  hyperopic  refraction  which  follows  cataract  ex- 
traction, a  certain  amount  of  regular  astigmatism  is  the  result  of  the 
operation,  due  probablj^  to  failure  of  the  wound  to  heal  evenl}'-  on 
account  of  inaccurate  coaptation  of  its  edges,  caused  by  the  character 
of  the  incision  or  b}^  some  condition — for  example,  badly  applied  dress- 
ings— during  convalescence.  This  astigmatism  is  generally  ''inverse," 
and  is  often  higher  during  the  first  month  or  two  after  the  extraction, 
or  until  cicatrization  is  complete,  than  it  is  at  a  later  period.  Usualh^ 
not  more  than  3  D  remain  permanently,  but  even  1  D  should  be  sought 
out  and  corrected.  Naturalh^,  prolapse  or  incarceration  of  the  iris 
causes  a  very  high  degree  of  astigmatism. 

Glasses  should  not  be  adjusted  until  all  redness  has  disappeared 
from  the  eye,  and  they  should  not  be  worn  constantly  at  first.  It  is 
wise  to  wait  from  six  weeks  to  two  months  before  ordering  the  glasses 
for  constant  use. 

The  amount  of  vision  obtained  after  a  cataract  extraction  varies 

quite  considerably.     Perfect  vision  is  frequently  secured — i.  e.,  ^  (  — ) ' 

but  often  patients  must  be  content  with  lower  degrees,  3^  or,  according 
to  some  operators,  J-lo  of  normal  vision  being  considered  sufficient  to 
place  the  case  within  the  category  of  successes,  but  vision  of  this  grade 
does  not  constitute  a  satisfactorj^  success  even  if  it  be  conceded  that 
it  is  an  operative  success. 

Acuteness  of  vision  may  be  considerably  raised  often  to  the  normal 
standard  by  successfully  dividing  the  capsule  of  the  lens  which  remains 
behind,  and  some  surgeons  perform  this  operation  almost  as  the  rule 
(see  Operations).  One  of  the  chief  advantages  of  successful  intracap- 
sular operations  is  that  secondary  operations  are  not  required.     Re- 


448 


DISEASES    OF   THE    CRYSTALLINE    LENS 


moval  of  a  ciBntral  piece  of  the  anterior  capsule  with  capsule  forceps 
usually  obviates  the  necessity  of  secondary  operations. 

Apparent  accommodation  in  aphakia  has  been  noted.  The  various 
theories  offered  in  explanation  of  this  jihononienon  have  been  summa- 
rized bj^  Zentmayer:  increase  in  the  index  of  the  refractive  mecha; 
partial  regeneration  of  the  lens;  eliminating  the  circles  of  diffusion  by 
contraction  of  the  pupil,  by  a  small  opening  in  the  after-cataract  or 
by  contracting  the  fissure  of  the  lids:  and  forward  bulging  of  the  an- 
terior surface  of  the  vitreous.  The  adjustment  of  the  correcting  lens  for 
distance  maj'  explain  some  of  the  cases;  in  others  elimination  of  the 
circles  of  diffusion,  as  noted  above,  would  seem  to  account  for  the 
condition. 


Fig.  201. — Spontaneous  dislocation  of  Ic-ns  into  tlio  anterior  chamber  of  highly 
myopic  eye  (from  a  patient  in  the  Philadelphia  General  Hospital.  Drawing  by  Dr. 
Randall). 


Dislocation  of  the  Crystalline  Lens. — This  may  be  congenital 

{ectopia  hntia),  and  is  duo  to  a  relaxation  or  al)Sonce  of  the  zonula. 
The  displacement  ordinarily  is  incomplete,  and  really  consists  in  a  de- 
centration  of  the  lens;  but  complete  congenital  luxation  is  also  described. 
Congenital  cases  are  usuallj'^  symmetric,  and  generally  the  displace- 
ment is  lateral,  upward,  or  upward  and  outward,  l^ut  in  (he  course 
of  time  the  lens  may  leave  this  p().>*iti(>n,  owing  to  elongation  of  the 
zonular  fibers,  and  be  displaced  downward  and  outwartl.  Several 
members  of  the  same  family  may  be  affected;  for  example.  G.  Griffin 
Lewis  has  reported  hereditary  ectopia  lentis  extending  through  six 
generations  and  involving  sixteen  individuals.  Unilateral  eases  are 
also  described. 

In  addition  to  congenital  dislocations,  there  are  those  due  to  dis- 
ease of  th(!  eye — c.  <j.,  choroiditis,  malignant  myopia,  etc. — and  tho.^^e 
caused  by  traumatism.  Traumatic  dislocation  may  also  1m>  incotiiplete 
or  complete;  if  tiie  latter,  the  lens  may  l)e  dislodged  from  its  nornud 
position  backwarti  into  the  vit  reous,  forw.ard  into  tiie  anteiior  chaml)er, 
or,  through  a  woun<l,  licneath  t  he  (•(nijnnct  iwi,  ;ind  even  under  Tenon's 
capsule. 


DISLOCATION    OF    THE    CRYSTALLINE    LENS 


449 


Symptoms. — If  the  dislocation  is  partial,  the  margin  of  the  lens 
may  be  seen  as  a  dark  line  with  the  ophthalmoscope,  the  refraction  of 
the  eye  will  vary  according  to  the  point  through  which  it  is  observed 
(i.  e.,  through  the  lens  or  beyond  it),  the  iris  is  tremulous  from  loosening 
of  the  suspensory  ligament  and  lack  of  the  support  of  the  lens  {irido- 


FiG.  202.- 


-Congenital  dislocation  of  the  crystalline  lenses,  up  and  out  (patient  in  the 
University  Hospital). 


donesis),  and  monocular  diplopia  and  impaired  or  absent  power  of 
accommodation  are  demonstrable.  If  there  is  complete  posterior  luxa- 
tion, the  symptoms  are  much  the  same  as  when  the  lens  has  been  re- 
moved by  operation,  and  if  the  cause  of  the  dislocation  is  trauma,  the 
symptoms  of  the  injury — e.  g.,  hemorrhage,  etc. — maybe  present. 


Fig.  203. 


-Subconjunctival  dislocation  of  the  lens    (from   a  patient  in  the  Chester 
County  Hospital). 


A  dislocated  lens  usually  becomes  cataractous,  and  often  causes 
intense  pain  and  frequent  attacks  of  iritis,  or,  by  occluding  the  angle 
of  the  anterior  chamber,  may  give  rise  to  glaucoma. 

Treatment. — In  partial  dislocation  an  attempt  should  be  made  to 
secure  the  best  vision  with  suitable  glasses.  Sometimes  it  is  possible 
to  remove  an  incompletely  congenitally  luxated  lens  by  linear  extrac- 
tion following  a  discission. 


450 


DISEASES    OF   THE    CRYSTALLINE    LENS 


In  complete  luxation  into  the  anterior  chamber  the  lens  may  be 
removed  by  a  simple  corneal  incision.  For  removal  of  a  lens  dislocated 
into  the  vitreous  humor,  provided  it  is  producing  irritation,  a  scoop 
introduced  through  a  peripheral  corneal  incision  may  be  employed,  or 
the  operation  devised  \)y  the  late  C.  R.  Agnew  may  be  attempted.  In 
the  latter,  a  double  needle  or  "bident"  is  thrust  into  the  vitreous  humor 
far  enough  back  to  avoid  wounding  the  iris,  the  handle  of  the  instru- 
ment is  depressed,  the  lens  is  caught  and  brought  forward  through  the 
pupil  into  the  anterior  chamber,  and  removed  in  the  ordinary  way. 
Knapp  preferred,  in  these  circumstances,  after  thorough  local  anesthesia, 
to  expel  the  lens  by  methodical  external  pressure  through  an  upp)er 
corneal  section,  after  removal  of  the  speculum.  He  pressed  the  edge 
of  the  untler  lid  on  the  lower  part  of  the  sclera,  directl}'  toward  the 
center  of  the  eyeball.  If  this  failed,  he  introduced  a  wire  or  metal 
spoon  through  the  corneal  section  and  the  pupil,  and  extracted  the  lens 
in  this  way.     The  author  has  employed  this  method  with  satisfaction. 

If  the  lens  has  been  dislocated  beneath  the  conjunctiva,  it  should 
be  extracted  through  a  small  incision  made  directly  over  it. 

After  the  successful  removal  of  a  dislocated  lens  the  eye  should  be 
provided  with  cataract  glasses. 

Foreign  Bodies  in  the  Lens. — Foreign  bodies  lodged  in  the  lens 
usually  cause  general  opacity.  Occasionally  the  body  is  surrounded 
by  a  small  opacity  which  remains  localized,  the  remainder  of  the  lens 
being  clear.  If  a  piece  of  steel  or  iron  is  embedded  in  the  superfical 
layers,  it  may  be  dislodged  with  the  electromagnet,  and  even  from  the 
deeper  layers  by  the  powerful  magnet  of  Haab.  If  the  lens  is  opaciue 
the  whole  crystalline  lens,  with  the  foreign  body  in  it,  should  be  ex- 
tracted, lest  the  foreign  l)ody  become  displaced  and  disappear  within 
the  eye.  If  any  difficulty  is  experienced  in  deciding  the  position  of  the 
foreign  body,  or  whether  a  foreign  body  is  really  in  an  opaque  lens,  the 
Rontgcn  rays  should  l)e  emi)loyed.  A  properly  preparetl  series  of  skia- 
grams will  |)i;i('tically  always  decide  the  question. 


CHAPTER  XIV 
DISEASES  OF  THE  VITREOUS 

Inasmuch  as  the  vitreous  after  birth  contains  no  blood-vessels  and 
is  not  subject  to  inflammation,  it  has  been  contended  that  the  term 
hyalitis  is  not  correct.  Straub,  however,  defends  its  use  in  that  he 
believes  that  irritants  in  the  vitreous  may  produce  chemotactic 
substances  which  attract  leukocytes  from  the  vessels  of  neighboring 
structures,  and  the  process  should  be  regarded  as  a  true  inflammation. 

Pus  in  the  Vitreous  {Abscess  of  the  Vitreous). — This  condition  is 
caused  by  a  penetrating  injury,  a  foreign  body,  or  a  purulent  choroid- 
itis, for  instance,  a  metastatic  choroiditis  after  inflammation  of 
the  cord  in  newborn  children,  or  after  scarlet  fever,  erysipelas,  re- 
lapsing fever,  basic  meningitis,  cerebrospinal  meningitis,  etc.  (see  also 
page  385). 

Purulent  collections  in  the  vitreous  may  complicate  the  infectious 
diseases  or  may  be  caused  by  an  infection  which  passes  through  an 
operation  scar  from  a  few  months  to  many  years  after  apparent 
healing.  Cystoid  cicatrices  are  particularly'  dangerous  in  this  respect. 
The  entrance  of  bacteria  may  be  facilitated  by  the  presence  of  pro- 
lapsed iris  tissue,  thinness  of  the  scar,  a  fistula,  and  insufficient  nour- 
ishment of  the  cicatricial  tissue.  On  experimental  grounds  a  defect 
in  Descemet's  membrane  appears  to  be  necessary  to  permit  the 
microbes  to  pass  into  the  deeper  tissue  of  the  eye.  Even  where  the 
scar  is  dense  and  there  is  no  fistula,  bacteria  may  enter  (Dolganoff 
and  Sokoloff). 

Symptoms. — If  the  cornea  is  clear,  a  yellowish  reflex  is  seen  shining 
through  the  pupillary  space,  there  are  retraction  of  the  periphery 
of  the  iris  and  bulging  of  its  pupillary  border.  Usually  one  or  two 
synechise  are  present  and  the  tension  is  diminished.  In  addition  to 
this,  there  may  be  a  pericorneal  zone  of  congestion  connected  with  the 
inflammation  of  the  iris  and  ciliary  body. 

If  the  exudation  in  the  vitreous  is  circumscribed,  the  symptoms 
at  the  first  glance  are  not  unlike  those  of  glioma  of  the  retina,  aiid  the 
name  pseudoglioma  has  been  given  to  this  condition,  especially  as  it  is 
seen  in  children.  It  is,  however,  to  be  distinguished  from  a  true 
glioma  of  the  retina  by  the  history  of  the  case,  the  usual  presence  of 
the  signs  of  iritis,  the  retraction  of  the  periphery  and  bulging  of  the 
pupillary  border  of  the  iris,  and  the  diminished  tension  of  the  globe. 

These  cases  of  'pseudoglioma  or  ophthalmitis  are  especially  note- 
worthy as  they  occur  in  children  and  young  subjects  suffering  from 
meningitis.  There  is  purulent  inflammation  of  the  uveal  tract,  w^ith 
deposits  of  exudation  in  the  vitreous  which  give  rise  to  the  yellowish 
appearance  which  can  be  seen  through  the  pupil      The  retina  is  de- 

451 


452  DISEASES    OF   THE   VITREOUS 

tached  and  the  optic  norvc  inflamed.  The  affection  has  been  attrib- 
uted to  an  extension  of  inflammation  from  the  meninges  along  the 
optic  nerve,  but  Percy  Flemming  suggests  that  the  meningitis  and 
ophthahnitis  are  both  the  result  of  a  pyemic  process.  The  source  of 
the  pyemia  may  be  middle-ear  disease.  Stephenson  urges  examina- 
tion of  the  pus  in  the  eye  for  the  mening'  coccus  (Diplococcus  intra- 
cellularis  meningitidis).  This  micro-organism  is  also  responsilile  for 
some  cases  of  purulent  conjunctivitis  (see  also  page  201).  Among  43 
cases  of  ophthalmitis  there  have  been  7  deaths,  6  from  meningitis 
(see  also  page  385).  George  Coats  and  J.  Graham  Forbes  have 
carefully  investigated  the  relation  of  the  Meningococcus  intracellularis 
to  pseudoglioma,  and  believe  that  a  causal  relation  may  be  established 
between  this  organism  and  this  disease. 

Treatment. — If  pus  has  once  formed  in  the  vitreous,  in  the  manner 
just  described,  no  medicinal  treatment  is  of  avail;  the  ball  will  shrink 
and  enucleation  is  usually  necessary.  Intra-ocular  injections  of 
chlorin  water  have  been  recommended. 

If,  during  the  earlier  stages  of  this  affection — for  instance,  during 
the  course  of  a  low  fever — the  discovery  is  made  that  fine  flakes  of 
opacity  are  beginning  to  appear  in  the  vitreous,  it  is  possible  that  a 
vigorous  supporting  treatment  ma}'  save  the  eye  from  destriiction 
(Hansell) . 

Opacities  in  the  Vitreous. — These  are  either  fixed  or  moving, 
and  vary  considerably  in  shape,  size,  and  somewhat  in  color.  The 
opacities  may  appear  in  the  form  of  membranes,  bands,  dots,  threads, 
flakes,  and  strings;  or,  finally,  the  entire  vitreous  humor  may  give 
evidence  of  uniform  loss  of  translucency,  which  on  careful  focusing 
resolves  itself  into  a  diffuse,  dust-like  opacity. 

The  fixed  membranous  opacities  usually  are  adherent  by  two  or 
more  points  to  the  choroid,  retina,  optic  disk,  and  sometimes  to  the 
ciliary  processes,  and  even  to  the  posterior  capsule  of  the  lens.  They 
may  exist  as  a  membrane  which  crosses  the  vitreous  and  covers  the 
optic  disk,  or  as  membranous  bands  running  from  before  backward, 
and  may  be  coarse,  dense,  and  organized,  or  fine  anil  more  like  a  cob- 
web in  textui-e. 

Method  of  Detection. — The  examination  of  tlie  vitreous  is  made  after 
the  manner  described  on  page  103. 

The  rapidity  with  which  the  Ixxlies  move  dep(>nds  upon  tlu>  con- 
sistency of  the  vitreous  humor;  if  this  is  normal,  the  movement  is  slow; 
if  it  is  fluid  or  semifluid,  the  movement  is  correspontlingly  rapid. 

The  diflerent  layers  of  the  vitreous  nuiy  also  be  examineil  for  fixed 
opacities  by  means  of  the  uprigiit  image  in  the  ordinary  way.  by  fust 
finding  the  o])tic  papilla,  Ihcn  gradually  placing  stronger  and  stronger 
convex  h'uses  beliind  the  sight-hole  of  the  mirror  until  a  +  Hi  D  is  in 
position,  thus  bringing  everything  into  focus  from  Itehiiitl  forward.  The 
observer's  head  nmst  be  close  to  the  observed  eye. 

The  subjective  symptoms  of  vitreous  oi)acities  depend  entirely  upon 
their  amount  ;iii(l  density.      There  lu.ay  be  little  or  no  depreciation  (^f 


OPACITIES    IX    THE    VITREOUS  453 

central  vision,  or  this  may  be  diminished  and  even  entire!}'  obHterated. 
Patients  frequently  are  conscious  of  black  and  gray  spots  before  their 
eyes;  sometimes  these  assume  fantastic  shapes,  and  not  infrequently 
these  shapes  repeat  themselves  so  constant!}'  that  the  patient  is  able 
accurately  to  describe  them.  The  same  sj'mptoms  may  appear  where 
there  is  no  organic  disease  (see  page  454).  Alterations  in  the  field  of 
vision,  pain,  redness  of  the  eye,  or  similar  conditions  will  depend  largely 
upon  associated  changes,  and  usually  are  absent  if  the  vitreous  alone 
is  affected. 

Causes. — 1.  Refractive  error,  generally  liigh  degrees  of  myopia  asso- 
ciated with  changes  in  the  choroid  and  posterior  staphjdoma. 

2.  Diseases  of  the  eye,  chiefly  cyclitis,  iridocyclitis,  uveitis,  choroid- 
itis, and  retino-retinitis. 

The  shape  and  character  of  the  opacities  var\'  with  tlie  condition 
whicli  has  caused  them.  In  cyclitis  and  iridocyclitis  so-called  ''in- 
flammatory opacities"  are  seen,  in  certain  varieties,  somewhat  circular 
in  shape,  resembling  large  mutton-fat  drops;  in  chronic  and  old-standing 
choroiditis  flake-lilce  or  thread-like  opacities  are  very  common,  espe- 
cially in  elderly  people,  an-^  are  probably  due  to  hemorrhages  having 
their  origin  in  the  choroid.  In  syphilitic  choroiditis  and  retinitis,  in 
addition  to  large,  floating  opacities,  there  may  be  a  diffuse  mist  which 
resolves  itself  into  the  so-called  dust-like  opacities  {hyalitis  'punctata), 
and  is  almost  characteristic  of  the  disease  which  has  caused  the  original 
inflammation  of  the  choroid  and  retina.  These  dust -like  opacities  are 
either  diffused  throughout  the  entire  vitreous  chamber,  or  are  situated 
in  its  posterior  layers,  or  anteriorly,  in  the  neighborhood  of  the  ciliary 
region. 

3.  Injuries  of  the  eye,  which  have  caused  a  hemorrhage  from  the 
choroid  or  ciliary  region.  The  origin  of  the  opacity  is  an  extravasation 
of  ^blood.  In  the  latter  case,  as  has  already  been  mentioned,  suppura- 
tion of  the  vitreous  may  occur. 

4.  Diseased  Conditio7is  of  the  System,  Local  or  General. — Infectious 
diseases,  wide-spread  endarteritis,  arteriosclerosis,  gout,  syphilis, 
tuberculosis,  malaria,  portal  congestion,  anemia,  and  irregular  or  sup- 
pressed menstruation  may  be  responsible  for  vitreous  opacities;  also 
the  prolonged  action  of  arsenic. 

5.  Absence  of  Apparent  Cause. — Opacities  of  various  shapes,  often 
fine  and  thread-like,  and  commonly-seen  in  old  people,  occur  without 
evident  disease  of  the  uveal  tract,  retina,  or  optic  nerve.  Their  pres- 
ence in  some  instances  is  without  serious  import. 

Sometimes,  indeed  not  very  infrequently,  the  vitreous  is  studded 
with  minute  light-colored  spheres;  possibly  a  congenital  condition, 
named  asteroid  hyalitis  bj'  Benson.  The  condition  has  been  well 
described  in  this  county  by  Stark  and  by  Holloway.  According  to  the 
latter  author  the  opacities  ("snow-ball  opacities"  he  has  named  them) 
are  globular  or  ellipsoid  in  shape,  dull  white  and  not  glittering  in  appear- 
ance as  is  cholesterin.  They  are  most  frequently  seen  in  elderh^  persons 
and  are  not,  according  to  Holloway,  congenital.     Their  composition  is 


454  DISEASES    OF   THE   VITREOUS 

unknown,  except  that  they  are  probably  not  cholesterin;  it  may  be 
they  contain  calcium.  WTiite,  glistoninj?  spots  in  the  vitreous  have 
also  been  described  as  evidences  of  fatty  degeneration. 

Prognosis. — This  depends  entirely  upon  the  cause  of  the  vitreous 
disease.  If  this  has  started  in  a  purulent  disease  of  the  choroid  or  a 
purulent  change  in  the  vitreous  has  taken  place,  the  prognosis  is  ex- 
ceedingly unfavorable,  and  the  eye  goes  on  to  destruction. 

If  the  cause  of  the  disease  is  syphilis  or  other  constitutional  condi- 
tion amenable  to  treatment,  satisfactory  clearing  of  the  vitreous  may 
be  expected;  even  very  dense  opacities  will  disappear  under  proper 
treatment.  When  the  opacities  are  due  to  hemorrhage,  although  ab- 
sorption of  the  clot  may  take  place,  fragments  and  strings  of  fibrin 
remain.  Both  hemorrhagic  opacities  and  others  are  subject  to 
relapses. 

Treatment. — In  any  case  of  vitreous  opacity,  provided  the  general 
fundus  of  the  eye-ground  justifies  this,  and  there  is  reason  to  believe 
that  eye-strain  in  any  sense  is  connected  with  its  cause,  suitable  lenses 
should  be  ordered,  but  the  use  of  the  eyes  at  close  ranges  should  be 
discouraged. 

In  syphilitic  vitieous  disease  the  usual  remedies  are  indicated.  If 
the  vitreous  change  is  associated  with  an  exhausted  conditon  of  the 
system,  supportive  measures  are  indicated. 

If  the  patient's  condition  warrants  it,  excellent  results  foMow  sweats 
induced  with  pilocarpin,  or  by  means  of  Turkish  baths  or  in  an  ordinary 
electric  lighted  cabinet.  lodid  of  potassium  and  sodium  are  useful, 
as  is  syrup  of  hydriodic  acid. 

If  the  disease  which  implicates  the  vitreous  depends  upon  consti- 
pation and  portal  congestion,  in  addition  to  regulated  diet  cholagogue 
laxatives  should  be  administered.  Anemia  and  menstrual  irregulari- 
ties are  evident  indications  for  treatment;  in  the  former  case  the  com- 
bination of  bichlorid  of  mercury  with  iron  is  useful.  If  there  is  an 
active  inflammatory  condition,  blood-letting  from  the  temple  may  be 
practised;  in  fact,  the  treatment  becomes  that  which  is  suited  to  the 
acute  inflammation  which  has  started  the  disorder.  The  use  of  the 
galvanic  current  has  been  warmly  recommended  by  some  surgc^ons 
in  vitreous  opacities.  Elschnig  has  treated  a  certain  munber  of  eyes 
with  vitreous  opacities  following  hemorrhage  by  aspirating  3^^  c.cm. 
of  vitreous  and  replacing  it  with  normal  saline  solution. 

Muscae  volitantes  (nn/oilesapia)  are  the  black  specks  and  motes 
often  seen  in  the  field  of  vision,  esiK'cially  if  tiie  eye  is  tlirected  toward 
a  bright  surface.  They  follow  the  movements  of  the  eye,  and  are 
especially  annoying  during  the  act  of  reading,  as  they  float  across  the 
page.     They  do  not  actually  interfere  with  vision. 

There  is  no  trii<>  opacity  of  tlic  vitreous,  and  the  oplithalmoscope 
fails  to  detect  in  these  instances  opaijuc  particles.  They  are  probMl)ly 
due  to  the  sha(U)Ws  thrown  upon  tiie  retina  by  naturally  formed  ele- 
ments in  the  vitreous  bodies,  perhaps  the  remains  of  embryonic  ti.*^sue. 
Corpuscles  in  I  he  rel  in.-d  vessels  may  be  seen  by  looking  I  hrough  a  dark- 


HEMORRHAGE    INTO    THE   VITREOUS  455 

blue  glass  at  a  white  cloud.  They  appear  as  small  oval  bodies,  some- 
times as  strings  of  minute  globules. 

Although  of  no  serious  import,  as  far  as  sight  is  concerned,  these 
muscae  produce  an  amazing  amount  of  annoyance  in  nervous  and  sensi- 
tive persons.  Patients  frequently  maintain  that  they  obscure  an 
object,  floating  directly  in  front  of  it,  and  they  assume  exaggerated  and 
fantastic  shapes.  They  are  often  ascribed  by  the  laity  to  disorders  of 
digestion  and  torpidity  of  the  liver,  and  are  aggravated  by  the  habit 
which  their  possessors  form  of  searching  for  them. 

Treatment. — Eye-strain  should  be  removed  by  the  adjustment  of 
suitable  lenses,  and  a  course  of  alterative  tonics  may  be  ordered. 

Hemorrhage  into  the  Vitreous. — As  has  already  been  stated, 
many  vitreous  opacities  result  from  hemorrhages  from  the  vessels  of 
the  choroid,  ciliary  body,  or  retina.  Hemorrhage  into  the  vitreous 
may  result  from  anemia,  nephritis,  diabetes,  arteriosclerosis,  myopia, 
and  glaucoma.  According  to  Ridley,  if  the  hemorrhage  arises  from 
the  retinal  vessels,  the  hyaloid  is  usually  detached  and  the  blood  lies 
between  this  rnembrane  and  the  vitreous.  If  the  ciliary  body  is  the 
source  of  the  hemorrhage,it  usually  bursts  through  the  hyaloid  into 
the  vitreous.  Eetinal  detachment  maj''  occur,  especially  if  the  hemor- 
rhage recurs  on  several  occasions.  Injury  is  a  common  cause  of  hemor- 
rhage in  the  vitreous,  and  in  such  circumstances  the  entire  chamber 
may  be  so  filled  with  blood  that  it  is  easily  detected  in  its  natural  color 
as  a  dark-red  clot,  sometimes  being  so  dense  that  no  reflex  comes  from 
the  fundus. 

Finally,  in  certain  cases,  generally  in  young  male  adults,  ranging  in 
age,  in  Eales'  series,  from  14  to  20,  but  occurring  also  at  a  somewhat 
later  age,  (the  female  sex  is  not  immune),  spontaneous  hemorrhage 
into  the  vitreous  occurs,  together  with  hemorrhage  in  the  retina 
{recurrent  retinal  hemorrhage).  According  to  Eales  such  patients 
are  "below  par,"  are  liable  to  constipation,  irregularity  of  the  circula- 
tion, and  epistaxis.  The  condition  has  also  been  ascribed  to  gout 
(Hutchinson),  but  recurrent  hemorrhages  from  this  source  and  from 
menstrual  anomalies  belong  to  a  different  class,  to  persistent  oxaluria 
(Leber),  to  enterogenous  auto-intoxication  and  to  focal  infections. 
There  seems  no  doubt  that  this  affection  may  be  one  of  the  manifesta- 
tions of  disturbance  of  the  functions  of  the  endocrine  organs,  as  Zent- 
niayer  points  out  in  his  recent  discussion  of  this  subject.  The  same 
suggestion  has  also  been  made  by  Fridenberg.  The  investigations  of 
Axenfeld  and  Stock  indicate  that  an  important  etiologic  factor  in 
recurring  intra-ocular  hemorrhage  in  adolescence,  as  well  as  in  pro- 
liferating retinal  lesions  and  retinal  periphlebitis  (see  also  page  482) ,  is 
tuberculosis,  the  active  agent  being  a  tuberculous  toxin.  The  author 
has  made  some  clinical  examinations  in  confirmation  of  this  statement 
and,  recently,  some  observations  with  Perry  Pepper  on  myocardial 
changes  in  the  subjects  of  this  affection.  There  is  marked  disturb- 
ances of  vision  depending  on  the  density  of  the  clot,  which  is  likely  to 
be  imperfectly  absorbed,  but  often  the  resorption    of  the  blood  is 


456  DISEASES    OF    THE    VITREOUS 

unusually  rapid,  oiil^^  to  be  followed  by  a  recurrence  of  the  hemorrhage. 
To  these  frequently  recurring  hemorrhages  into  the  vitreous  the  term 
"malignant"  has  been  applied.  It  is  possible,  as  Coats  suggests, 
that  anomalies  in  the  coagulability  of  the  blood  may  account  for 
many  of  these  cases.  As  the  result  of  repeated  hemorrhages  vitreous 
membranes  may  form,  retinitis  proliferans  and  even  glaucoma  may 
arise  (one  case  occurred  in  Bales'  series).  The  source  of  the  blood  is 
probably,  if  not  certainly,  the  veins  of  the  retina,  although  the  ciliary 
body  and  choroidal  vessels  have  also  been  accused  in  this  regard. 

Treatment. — This  should  consist  in  the  administration  of  cardiac 
sedatives,  laxatives,  and  later  of  iodid  of  potassium  or  sodium,  accord- 
ing to  the  circumstances.  If  arteriosclerosis  is  present,  the  usual 
treatment  of  this  condition  is  indicated.  Sometimes  instead  of  ele- 
vated there  is  lowered  arterial  tension.  The  administration  of  calcium 
salts  to  aid  the  coagulability  of  the  blood  is  worthy  of  trial;  coagulose 
and  pituitrin  may  be  administered  and  thyroid  extract  has  been  suc- 
cessfully employed.  Fibrolysin  has  been  advocated.  Injections  of 
hemolytic  serum  have  been  tried,  but  with  disastrous  results  (Elschnig). 
Intravenous  injections  of  human  blood-serum  have  been  used  (A.  E. 
Davis)  and  also  of  horse-blood  serum.  Ligation  of  the  carotid  for 
recurring  hemorrhage  into  the  vitreous  has  been  performed,  and  in  a 
few  instances,  it  is  said,  with  success.  As  in  other  vitreous  changes, 
if  the  general  condition  permits  it,  a  sweat-cure  may  be  instituted, 
either  by  means  of  the  Turkish  bath  or  with  pilocarpin;  active  diuresis 
is  advisable.  Enterogenous  auto-intoxication  should  be  corrected 
as  well  as  all  other  sources  of  focal  infection.  Because  of  the  relation 
of  tuberculosis  to  this  condition  the  advantages  of  tuberculin  treatment 
should  be  considered. 

Synchysis  {Fluidity  of  the  Vitreous). — This  is  a  softened  or  fluid 
condition  of  the  vitreous,  which,  as  has  already  been  implied,  can  be 
positively  diagnosticated  or,  rather,  assumed  to  be  present  only  by 
noticing  the  rapid  movement  of  particles  of  opacity  contained  within 
it  dui'iiig  motions  of  the  eye*  Although  tremulousness  of  the  iris  is 
sometimes  seen  where  there  is  decided  fluidity  of  the  vitreous  humor, 
this  symptom  does  not  prove  its  condition,  but  only  a  lack  of  support 
by  the  crystalline  lens  owing  to  relaxation  of  the  zonula.  The  t<'nsion 
of  the  eyeball  may  be  diminished  (hy polony). 

It  occurs  in  eldeily  jx'ople  with  disease  of  the  choroiilal  coat  anil  in 
high  myopia.  A  fluid  vitreous  is  a  complication  of  serious  import  in 
cataract  extraction. 

Synchysis  scintillans  is  a  term  applied  to  a  fluid  vitreous  which 
holds  in  suspension  numerous  scales  of  cholesterin  which  move  with 
great  ra[)idity  a(,'ross  the  ophthalinoscoi)ic  field  and  pioihu'c  a  striking 
jjicture,  resend)ling  a  shower  of  brilliant  crystals.  Poncet  has  reported 
in  this  connection  tyrosin  and  ciystalli/ed  phosphates,  but  investiga- 
tions seem  to  show  that  the  appearance  is  due  solely  to  cholesterin. 

The  afi'eclion  prol)al)l\'  depends  upon  a  choioiditis,  is  essentially 
a  coiidilioii  of  ;i<l\aiic<'d  \cais,  and  is  said  (o  Itc  nioic  conuuon  among 


FOREIGN   BODIES    IN    THE   VITREOUS 


457 


alcoholic  subjects  and  those  with  arthritic  tendency  or  any  serious 
disorder  of  nutrition;  syphilis,  arteriosclerosis,  albuminuria,  diabetes 
have  been  noted  as  possible  etiologic  factors;  some  cases  appear  to 
have  a  traumatic  origin  (Roemer).  The  affection  is,  however,  clini- 
cally at  least,  seen  in  eyes  which  apparently  are  not  diseased  in  other 
portions,  especially  in  old  people,  and  may  be  present  in  advanced 
degree  without  depreciation  of  visual  acuteness.     (See  also  page  453.) 

Treatment. — This  does  not  appear  to  have  any  influence.  Suc- 
cinate of  iron  has  been  recommended. 

Blood=vessel  Formation  in  the  Vitreous. — Occasionally  cases 
are  examined  which  present  an  entirely  new  blood-vessel  formation  in 
the  vitreous  in  front  of  the  entrance  of  the  optic  nerve  (Fig.  204). 


Fig.  204. — New  blood-vessel  formation  in  the  vitreous. 


Only  a  few  vessels  may  be  present  or,  in  extreme  cases,  the  entire 
disk  is  obscured  by  a  congeries  of  contorted  vessels,  the  whole  forming 
an  extensive  vascular  veil  of  anastomosing  capillaries  coming  directly 
from  the  nerve-head  and  having  no  connection  with  the  retinal  vessels. 
The  vessels  may  owe  their  origin  to  vitreous  and  to  retinal  hemorrhages; 
in  other  cases  syphilis  is  the  etiologic  factor.  The  relation  of  tuber- 
culosis to  this  and  similar  conditions  has  been  described.  (See  also 
pages  480  and  482.) 

Foreign  Bodies  in  the  Vitreous. — These  are  usually  chips  of 
steel,  splinters  of  glass,  particles  of  gun-cap,  or  small  shot  or  fragments 
of  shrapnel.  They  may  reach  the  vitreous  by  penetrating  the  sclera 
directly  or  by  passing  through  the  cornea  and  lens.  The  foreign  body 
may  convey  infection  into  the  injured  eye;  sympathetic  ophthalmitis 
may  develop.  The  symptoms,  diagnosis,  and  treatment  of  foreign 
bodies  in  the  vitreous  have  been  included  with  injuries  of  the  sclera 
on  pages  318-321. 


458 


DISEASES    OF   THE   VITREOUS 


Entozoa  in  the  Vitreous. — Three  different  species  of  taijeworm 
larviB  are  known  to  occur  in  the  eye  and  its  adnexa,  namely,  those  of 
Taenia  soli  inn,  Taenia  echinococcus  and  the  bothriocephahd  tape- 
worms.    Of  these,  Cysticercus  cellulosae  is  the  most  common. 

Among  807  observations  on  cysticercus  tabulated  by  Vosgien,  372 
were  concerned  with  the  eye,  and  of  these,  120  of  the  retina  and  112 
of  the  vitreous  (quoted  from  Ward).  None  the  less,  in  individual  ex- 
periences ocular  cj'sticercus  is  rare. 

The  intra-ocular  situation  of  the  parasite  may  be  in  the  anterior 
chamber,  in  the  posterior  chamber,  even  in  the  lens,  in  the  posterior 
segment  of  the  eye,  that  is.  under  the  retina  and  in  the  vitreous. 


Fig.   205. — Cysticercus  of  the  vitreous,      (from  :i  patient  at  I'ort  Otiplthorpe.  Ga.) 

Most  frequently  the  parasite  has  been  I'tuiiul  in  the  retina,  having 
gained  entrance  into  the  vessels  of  the  choroid,  and  from  tiiere  passed 
beneath  the  retina,  which  it  detaches  from  the  choroid.  The  appear- 
anc(>s  are  those  of  a  bluish-gray  ])la(lder,  with  a  margin  of  lighter 
color,  usually  under  a  circumscribed  retinal  detachment;  spon- 
taneous movements  are  sometimes  visibU;.  The  paiasitt>,  however,  is 
able  to  develop  floating  in  tlu>  vitreous  (von  Graefe,  Fuchs)  having 
found  its  way  into  a  vessel  of  the  retina  or  ciliary  body.  If  the 
parasite  is  free  in  the  vitreous  the  appearances  may  be  as  they  are 
depicted  in  the  accompanying  diiigram  from  a  case  studied  l)y  the 
author  and  Meyer  Wiener.  Distinct  jx  listaltic  motions  and  the 
movements  of  the  hard  nccU  and  Ixxly  were  visible.  Usually  a 
progressive  iridocyclitis  develops.  An  en(le;i\'or  to  remove  the  p;ir:\sit(> 
through  !i  scleral  incision  should  be  made. 


/ 


PERSISTENT    HYALOID    ARTERY  459 

At  one  time  this  condition  was  most  frequent  in  northern  Germany, 
but  even  here,  owing  to  the  improvement  in  meat  inspection,  etc., 
there  has  been  a  noticeable  diminution  of  this  form  of  tapeworm 
infection.  So  far  as  the  author  is  aware,  Taenia  solium  has  not 
been  found  in  native  Americans,  but  only  in  those  who  have  emi- 
grated to  this  country,  and  even  so,  it  is  very  rare  among  them. 

Another  parasite  which  has  been  seen  in  the  vitreous,  the  removal  of 
at  least  one  specimen  being  on  record,  is  the  Filaria  sanguinis  hominis. 

Detachment  of  the  vitreous  except  in  the  region  of  the  ciliary 
body  where  separation  does  not  occur,  is  produced  by  an  accumulation 
of  fluid  between  it  and  the  retina. 

Traumatism,  choroiditis,  hemorrhages,  intra-ocular  growths,  and 
staphyloma  may  cause  it.  The  vitreous  humor  is  said  to  be  occa- 
sionally detached  without  change  in  its  translucency,  although 
opacities  are  usualh^  present.  Shrinking  of  the  vitreous  after  a  blow 
on  the  eye  causes  its  hyaloid  to  be  detached  from  the  retina.  In 
eyes  removed  after  injury,  stretching  across  the  globe  behind  the  lens, 
the  so-called  cy clitic  7nembrane  may  be  seen.  Elschnig  has  pointed  out 
that  many  so-called  vitreous  detachments  depend  upon  artifacts  the 
result  of  the  methods  used  in  preparing  the  specimens. 

Persistent  Hyaloid  Artery. — During  fetal  life  the  vitreous  humor 
is  traversed  by  the  hyaloid  artery,  which  is  an  extension  of  the  central 
artery  of  the  retina,  and  proceeds  from  the  optic  nerve  to  the  posterior 
surface  of  the  lens.  The  vessel  passes  through  a  channel  having  a 
delicate  membranous  lining,  known  as  the  canal  of  Cloquet.  Oblitera- 
tion of  this  artery  begins  at  the  end  of  the  fifth  month  of  gestation. 

Sometimes  obliteration  fails,  and  the  most  important  congenital 
anomaly  of  the  vitreous  is  evident — namely,  the  pereistence  of  some 
vestige  of  the  hyaloid  artery.     It  may  appear  in  the  following  forms: 

A  rudimentary  strand  attached  to  the  disk;  a  strand  attached  to  the 
disk  and  a  vestige  also  at  the  posterior  surface  of  the  lens;  a  strand 
passing  from  the  disk  to  the  lens;  a  similar  strand  containing  blood; 
a  strand  attached  to  the  lens  alone;  and  a  persistent  canal  (canal  of 
Cloquet)  without  any  remnant  of  the  vessel.  These  are  the  most 
ordinary  and  well-recognized  forms. 

In  addition  to  this,  shreds  of  tissue  and  membranes  on  the  optic 
disk,  masses  resembling  connective  tissue,  and  small  cj'stic  bodies  are 
probably  remnants  of  this  artery.  Its  role  in  producing  posterior 
capsular  cataract  has  already  been  described.  The  appearances  are 
readily  recognized  by  the  ophthalmoscope,  and  require  no  further 
description  than  the  names  already  given. 

This  classification  has  been  condensed  from  the  admirable  mono- 
graph of  Dr.  De  Beck  who  has  written  a  complete  account  of  the 
anomaly.  According  to  XJribe  Troncoso,  a  free  cyst  developed  from 
the  ciliary  processes  may  give  rise  to  the  appearance  of  a  vesicle 
floating  in  the  vitreous.  A  notch  in  the  lower  part  of  the  vitreous 
has  been  described  {colohojna  of  the  vitreous). 


CHAPTKI^    W 

DISEASES  OF  THE  RETINA 

Hyperemia  of  the  Retina. — Alth(HiL:li  tho  capillary  network  of 
the  retina,  invisible  in  ordinary  cireuinstancc^s,  may,  under  other  con- 
ditions, become  evident  (capillary  congestion) ,  the  presence  of  a  con- 
gestion is  inferred,  not  by  any  alteration  in  the  appearance  of  the  retina 
itself,  but  by  changes  in  the  surface  of  the  optic  disk,  generally  known 
by  the  terms  increased  redness  or  undue  capillarity,  and  is  associated 
with  increase  in  the  amount  of  the  retinal  striation  which  surrounds  the 
papilla,  so  that  its  edges  are  veiled  or  slightly  blurred.  Such  appear- 
ances are  common  in  asthenopic  and  ametropic  eyes,  and  in  persons 
whose  occupations  expose  them  to  the  glare  of  artificial  heat — e.  g., 
puddlers. 

It  is  possible  to  speak  with  more  confidence  of  a  change  in  the 
caliber,  course,  color,  and  general  size  of  the  retinal  vessels,  provided 
more  than  the  normal  amount  of  blood  finds  its  way  into  them  and  they 
are  distended,  tortuous,  or  positively  lengthened.  It  is  customary  to 
describe  the  hyperemia  as  active  if  an  increased  amount  of  blood  is  sent 
to  the  retina,  because  the  systemic  circulation  is  unduly  filled — e.  g., 
in  rapid  action  of  the  heart  with  fever,  pneumonia,  etc. — and  as  passive 
if  the  blood  is  not  properly  returned  from  the  eye,  for  example,  in  com- 
pression of  the  retinal  vein.  In  the  last-named  circumstance  the  veins 
are  large,  filled  with  dark  blood,  and  often  tortuous,  while  the  arteries 
are  unaffected  or  are  smaller  than  usual. 

Among  the  general  causes  of  a  stasis-hyperemia  may  be  mentioned 
mitral  disease,  emphysema,  violent  cough,  convulsive  s(Mzures,  or,  in 
short,  any  cause  which  is  likel}'  to  produce  engorgenuMit  of  the  veins  of 
the  head  and  neck,  and  to  prevent  the  emptying  of  their  contents  into 
the  great  venous  channels  of  the  chest.  Increase  in  the  diameter  of  the 
veins  is  nmch  mon;  fnujuent  than  increase  in  the  diameter  of  the  ar- 
teries, while,  on  the  other  hand,  increase  in  the  diameter  of  the  arteries 
is  unconunon  as  compared  with  a  diminution  of  their  calii)er.  Patho- 
logic significance  must  not  always  be  ascribed  to  apparent  changes 
in  the  (hameter  of  the  veins,  because  eye-grounds  are  often  cri)s.><ed  by 
large  dark  veins,  the  arteries  being  small  1)y  contrast,  witiu)Ut  definite 
local  or  general  cause  for  the  phenomenon. 

Ordinarily  patients  with  hyperemia  ol'  the  retina  do  not  presi-nt 
characteristic"  symptoms,  but  it'  the  condition  is  connected  with  ame- 
ti(>pi:i   tliere  :ire  ociilai'  pain,  phol()|)h(il)ia,  and  Lack  of  (>ye  endurance. 

Treatment.      In  hypeicniia  dependent  upon  errors  of  refraction  the 
evident  treatment  is  physiologic  rest  uiuler  the  influence  of  atropin, 
and  later  a  suitahle  correction   with   glasses.      If   the   foiKhtion   de- 
pends upon  general  (■.•luses,  these  furnish  the  indic-itinns  for  treatment, 
too 


HYPERESTHESIA    OF    THE    RETINA  461 

Anemia  of  the  retina  is  not  a  clinical  entity,  but  a  symptom  of 
local  pressure  or  of  some  cause  situated  within  the  general  economy. 

The  highest  type  of  anemia  of  the  retinal  vessels  is  seen  with  stop- 
page of  the  circulation  by  an  embolus  or  thrombus,  and  occurs  in 
marked  degree  as  the  result  of  compression,  in  consecutive  atrophy  of 
the  optic  nerve.  Other  causes  of  anemia  of  the  retina  are  general 
anemia,  cerebral  anemia,  and  syncope. 

Extreme  narrowing  of  the  retinal  arteries  is  occasionally  seen  as  the 
result  of  a  vasomotor  spasm — for  example,  in  "sick  headaches"  and  in 
true  migraine.  In  these  cases  there  may  be  temporary  complete  or 
partial  (hemianopic)  blindness.  If  the  blindness  approaches  from 
above  downward,  the  obstruction  is  in  the  retinal  circulation,  but  if  it 
assumes  a  lateral  form,  the  cortical  visual  centers  are  probably  affected 
(Priestley  Smith).  Impeded  retinal  circulation  may  be  attributed  to 
the  high  arterial  tension  which  is  known  to  be  present  in  some  cases 
of  migraine. 

Under  the  name  ischemia  of  the  retina  a  condition  is  described  in 
which,  with  complete  blindness,  there  are  pallor  of  the  optic  disks  and 
extreme  narrowing  of  the  retinal  blood-vessels.  This  is  visible,  for 
example,  in  the  collapse  stage  of  cholera  (Graef e) ,  in  whooping-cough 
(Knapp,  Noyes),  in  erysipelas  (Ayres),  and  under  the  influence  of 
toxic  doses  of  quinin,  ethylhydrocuprein  and  salicylic  acid. 

Treatment. — The  flagging  circulation  should  be  stimulated  by  digi- 
talis and  strychnin.  Nitrite  of  amyl  has  been  employed  in  spasm  of 
the  retinal  arteries.     General  anemia  calls  for  its  appropriate  remedies. 

Hyperesthesia  of  the  Retina. — This  is  characterized  chiefly  by 
the  symptoms  which  indicate  a  supersensitive  state  of  the  retina — dread 
of  light,  lacrimation,  blepharospasm,  neuralgic  pain,  and  imperfect  eye 
endurance. 

Ophthalmoscopic  changes  may  be  practically  absent,  but  in  most 
instances  those  lesions  will  be  detected  which  have  been  referred  to 
under  congestion,  but  which,  adopting  a  name  which  was  originally 
employed  by  Jaeger  and  later  used  by  Loring,  maj^  be  described  as  irri- 
tation of  the  retina.  These  are:  undue  redness  of  the  nerve-head, 
veiling  of  its  nasal  edges,  from  which,  and  from  those  above  and  below, 
distinct  striation  of  the  retinal  fibers  are  evident,  while  streaks  of  light 
tissue  can  be  followed  along  the  course  of  the  larger  vessels.  The 
margins  of  the  disk  are  veiled  by  this  retinal  striation,  and  although 
the  physiologic  cup,  or  the  ''light  spot,"  may  be  unchanged,  the 
general  surface  of  the  disk  seems  to  be  covered  with  a  delicate  layer  of 
edematous  tissue.  At  the  same  time  the  choroid  reveals  changes 
similar  to  those  described  on  page  372,  or  else  is  distinctly  granular 
and  macerated.  Often  the  entire  fundus  fails  to  present  a  distinct  oph- 
thalmoscopic picture,  and  ma}^  be  described  by  saying  that  the  details 
of  the  eye-ground  are  not  sharply  seen  with  the  aid  of  any  correcting 
glass. 

Causes.^ — Hyperesthesia  and  irritation  of  the  retina  are  usually 
caused  by  errors  of  refraction  and  anomalies  of  muscle  balance,  espe- 


462  DISEASES    OF   THE    RETINA 

cially  in  neurasthenic  and  hysteric  subjects.  They  also  owe  their 
orifiin  to  chronic  headache,  neuralgia,  sexual  abuses,  prolonged  fevers, 
pulmonary  disorders,  and  exposure  to  bright  light.  In  a  series  of  cases 
which  the  author  has  reported,  oxaluria  appeared  to  be  the  source  of 
trouble. 

In  some  instances  of  retinal  irritation  the  cause  seems  to  be  de- 
pendent upon  changes  in  the  nasoi^harynx;  for  example,  engorgement 
of  the  septum,  associated  with  myxomatous  and  hypersensitive  spots, 
vasoparetic  and  infiltrated  turbinals,  and  secondary  changes  in  the 
pharynx  and  larynx.  Just  as  areas  of  hyperesthesia  in  these  regions 
may  be  part  of  a  general  neurosis,  so,  also,  they  may  be  both  directly 
and  indirect!}'  connected  with  a  hyperesthetic  condition  of  the  retina, 
and  the  eyes  will  not  grow  comfortable  until  the  nasal  disease  is  cured. 
Retinal  irritation  may  sometimes  be  the  forerunner  of  organic  change 
in  the  optic  nerve  (Loring). 

Treatment. — Spectacles  are  not  a  panacea,  and  although  errors 
of  refraction  should  always  be  neutralized,  the  correcting  lenses  alone 
do  not  suffice  to  relieve  the  symptoms.  General  tonics,  rest,  massage, 
and  all  measures  calculated  to  overcome  debility  or  existing  neurosis 
are  required.  The  nasopharynx  should  be  explored.  A  thorough  ex- 
amination of  all  organs  should  be  instituted  and  treatment  directed 
according  to  the  findings.  Retinal  irritation  is  apt  to  be  exceedingly 
stubborn. 

Anesthesia  of  the  retina  {neurasthenic  or  nervous  asthenopia),  like 
several  other  disorders  of  the  retina  just  considered,  should  be  regarded 
not  as  an  affection  peculiar  to  the  eye,  but  as  one  of  the  symptoms  of  a 
complicated  neurosis.  Very  often  the  condition  described  in  the  pre- 
ceding paragraph  and  the  present  affection  are  closely  allied,  and  with 
neurastiienic  asthenopia  there  may  be  marked  hyperesthesia  and  irrita- 
tion of  the  retina.  On  the  other  hand,  such  appearances  may  be 
entirely  aljsent. 

The  subjective  symptoms  of  this  condition  have  been  arranged  by 
Wilbrand  and  others  as  follows:  Headache,  particularly  throbbing  in 
the  brow  and  temples,  occipital  distress,  pain  in  the  back  of  the  neck 
and  spine,  vertigo,  nmsca?  volitantes,  defective  accommodation,  intol- 
erance of  light,  and  improvement  in  vision  in  the  dusk  and  through 
tinted  glasses.  Any  attempt  at  concentrated  vision  is  followed  by  a 
rapid  disappcaiance  from  view  of  the  object  which  is  to  be  fixed. 
There  are  diniinution  of  central  vision,  sudden  attacks  of  obscuration  of 
vision,  processions  of  scotomas,  visual  hallucinations,  lack  of  fixation 
of  the  optical  memory  linages,  persistent  and  confusing  after-images, 
colored  vision — for  example,  erythropsia — and  a  red  appearam-e  of  the 
pages  of  H  book,  the  letters  of  whicii  seem  to  be  green. 

In  this  afTection  peculiar  alterations  of  the  visual  tield,  th(>  s«)-called 
fatigue  contractions,  aj)pear.  The  following  forms  have  been  des- 
cribed: The  shiftiiKj  or  (lispldccniiiil  type,  origin.'illy  inv(\sligated  by 
Forster,  in  which  the  visual  fields  dilTer  accoiding  ;is  tlie  examination 

is  CoildlU'tecl  fiotii  the  teliipniMl  side  to  tile  li;is;il,  ol'  I'loiii  the  nasal  side 


CYANOSIS    OF    THE    RETINA  463 

to  the  temporal,  the  contraction  being  pronounced  on  the  nasal  side 
in  the  former,  and  on  the  temporal  side  in  the  latter;  the  exhaustion 
type  of  Wilbrand,  in  which  the  test-object  is  moved  from  the  temporal 
side  to  the  nasal,  and  from  the  nasal  side  to  the  temporal,  several  times 
in  succession,  across  the  entire  width  of  the  perimeter — indeed,  as  often 
as  the  field  continues  to  diminish;  unstable  concentric  limitation — that 
is,  a  field  which  is  constantly  changing  during  examination;  the  ex- 
haustion-spiral type,  in  which  the  tracing  of  the  visual  field  appears 
coiled  Hke  a  watch-spring,  in  consequence  of  its  limits  becoming  con- 
centrically smaller;  and,  finally,  the  recuperation-extension  type,  in 
which  the  restricted  field  may  extend  during  rest  or  by  a  strong  effort 
of  will  (see  also  page  555). 

The  "oscillating  field"  described  by  Wilbrand  and  0.  Koenig  may 
also  be  found,  in  which  the  object  disappears  and  reappears  several 
times  in  the  same  meridian,  and  in  which  a  similar  oscillation 
occurs  with  colored  test-objects.  Such  fields  are  not  only  encountered 
in  so-called  nervous  asthenopia,  but  with  the  retinal  exhaustion  which 
is  found  in  a  variety  of  conditions. 

Patients  thus  affected  are,  for  the  most  part,  women,  often  the 
subjects  of  ovarian  and  uterine  diseases,  neurasthenia,  hysteria,  and 
chlorosis.  It  is  not  an  uncommon  affection  in  children  between  the 
ages  of  nine  and  fifteen,  in  whom,  in  addition  to  reduction  of  central 
visual  acuteness,  there  is  marked  contraction  of  the  visual  field.  Pure 
types  of  retinal  asthenopia  are  also  seen  in  men. 

Treatment. — This  should  include  all  suitable  general  measures,  and 
not  infrequently  a  "rest-cure,"  namely,  rest  with  seclusion,  forced 
feeding,  massage,  and  electricity. 

Although  tinted  glasses  are  recommended,  they  are  not  always  ad- 
visable, lest  the  affected  eyes  become  too  much  accustomed  to  the  dull 
light  afforded  through  such  protection.  Any  error  of  refraction  should 
be  corrected,  but  spectacles  and  treatment  designed  to  relieve  imbal- 
ance of  the  ocular  muscles  are  usually  not  alone  sufficient  to  cure  these 
patients.  It  should  be  remembered,  however,  that  errors  of  refraction 
are  often  the  source  of  the  trouble,  and  that  they  must  always  be  thor- 
oughly and  carefully  corrected  if  good  results  are  to  be  obtained.  The 
neglect  of  this  part  of  the  treatment  has  been  the  origin  of  many  cases 
of  chronic  invalidism. 

Cyanosis  of  the  Retina. — This  name  is  applied  to  an  ophthal- 
moscopic picture  seen  in  patients  with  congenital  heart  disease  and 
general  cyanosis.  The  vessels  of  the  fundus  are  dilated,  especially  the 
veins,  which  may  be  greatly  distended  and  tortuous.  They  carry 
blood  much  darker  than  is  normal,  and  the  arteries  resemble  in  color 
the  ordinary'  retinal  veins.  Small  hemorrhages  near  the  disk  and 
larger  ones  in  the  macula  may  be  present ;  sometimes  vision  is  normal ; 
sometimes  it  is  greatly  reduced.  The  ophthalmoscopic  appearances 
of  the  affection  were  first  described  by  H.  Knapp;  they  have  been 
studied  and  depicted  in  this  country  by  Posej',  H.  H.  Tyson,  and 
T.  B.  Holloway.     In  cyanotic  polycythemia  the  veins  of  the  fundus 


464  DISEASES    OF   THE    RETINA 

are  greatly  enlarged  and  are  very  dark  colored;  the  arteries  are  not 
materially  changed.  Retinal  hemorrhages  maj'  be  present  (E.  Jackson, 
Parker).  " 

Retinitis. — Under  the  general  term  retitiitis  are  included  the  var- 
ious types  of  inflammation  of  the  retina. 

Varieties  and  Causes. — Retinitis,  like  iritis  and  choroiditis,  may 
depend  upon  constitutional  disorders,  altered  states  of  the  l)lot)d  and 
blood-vessels,  infections,  auto-intoxication,  toxins  and  traumatisms, 
or  be  due  to  an  extension  of  a  diseased  process  from  an  inflamed  iris, 
ciliary  bodj^  or  choroid — that  is,  the  retinitis  is  either  primary  or 
secondary.  Retinitis  is  often  classified  according  to  the  probable 
etiology — for  example,  syphilitic,  rctuil,  diabetic,  hemorrhagic,  etc., 
retinitis.  It  is  further  divided,  according  to  its  character,  into  circum- 
scribed and  diffuse,  and  was  formerly  separated,  according  to  its  sup- 
posed pathologic  nature,  into  serous  and  parenchymatous  retinitis. 

Pathologic  Anatomy. — In  the  acute  stage  of  retinitis  the  retina  ex- 
hibits edema  and  infiltration  with  leukocytes  and  red  l)lood-corpuscles. 
White  areas  are  visible,  due  to  fatty  degeneration  of  both  nervous  and 
supporting  tissues,  varicosity  and  swelling  of  the  nerve-fiber,  and  to 
masses  of  fibrinous  exudation  in  the  granular  and  nuclear  layers.  The 
blood-vessels  are  thickened,  often  obliterated,  and  the  supporting  tissue 
hypertrophied.  In  the  later  stages  of  atrophy  the  retina  consists  of  a 
connective-tissue  network  which  contains  manj'  pigment  cells;  the  ner- 
vous elements  disappear,  and  the  blood-vessels  are  converted  into  solid 
cords.  In  brief,  as  Gmsberg  summarizes  the  matter,  the  changes 
which  present  themselves  for  consideration  include  edema  and  exuda- 
tion, hemorrhage,  and  small-celled  infiltration;  proliferation  of  the 
neuroglia  and  the  vessel  wall  connective  tissue;  degeneration  of  the 
retinal  elements,  the  vessels,  and  the  neurogliar  tissue;  and  pigmenta- 
tion. 

Symptoms. — Certain  objective  and  subjectirc  symptoms  are  present 
in  most  of  the  forms  of  retinitis. 

1.  Loss  in  the  Transparency  of  the  Retina. — This  may  manifest  itself 
as  a  faint,  diffuse  haze,  a  circumscribed  opacity  and  swelling,  or  as 
streaks  of  white  infiltration,  especially  along  the  lines  of  the  larger 
vessels. 

2.  Areas  of  Exudation. — These  are  an  advanced  stage  of  the  con- 
dition just  descrilx'd.  They  appear  as  white  spots,  sometimes  discrete, 
sometimes  confluent,  or  as  i)atches  of  l)luish-gray,  InitT.  or  yellowish 
('(Aor.  They  should  be  difTerentiated  from  the  shining  white  pia(iues 
due  to  atropliy  oi  the  choroid  by  their  softer  tone,  their  situation,  ;ind 
because  Iheic  is  an  absence  of  aceunndati«tn  of  clioroidal  pigment. 
They  m;i\'  be  i)resent  anywheic  in  ihe  retina  oi'  locaHzeil  in  the  macular 
region. 

'.\.  Tortuosity  of  the  \'es,^il.^  and  ChaiKje  in  Their  Calilter.  The  veins 
are  darker  than  norni.al.  imchily  wavy  in  outline,  or  positively  length- 
ened in  their  course.  The  .ntciics  ina\  not  l>e  inaltM'ially  changed,  but 
the  finer  transverse  blanches  ;ire  often  \'erv  t(»rtu()iis,  and  both  sets  of 


RETINITIS  465 

vessels  are  liable  to  displacement  from  their  normal  level  as  they  cross 
areas  of  thickening,  or  to  partial  obscuration  by  the  puffy  and  infil- 
trated retina.  Many  vessels  invisible  in  health  become  injected  in 
retinitis  and  form  a  fine  red  striation,  passing  from  the  nerve-head. 
Pulsation  of  the  vessels  is  readilj^  induced  by  pressure. 

4.  Hemorrhages. — These  occur  either  in  the  fiber-laj^er  or  the 
deeper  portions  of  the  retina.  The  presence  of  retinal  hemorrhage 
alone,  however,  does  not  indicate  the  existence  of  inflammation,  as  it 
may  occur  quite  independently  of  retinitis. 

If  the  hemorrhage  is  in  the  nerve-fiber  layer,  it  usually  assumes  a 
flame-shape,  with  frayed  or  feathery  edges;  if  its  situation  is  in  the 
deeper  layers,  it  has  a  cleaner-cut  border  and  more  rounded  shape. 

5.  Changes  in  the  Nerve-head. — More  or  less  change  in  the  optic 
papilla  is  present:  undue  redness,  loss  of  the  distinctness  of  its  margins, 
obscuration  by  the  swollen  and  pufiy  retinal  fibers,  or,  finally,  positive 
inflammation  or  neuritis.  Atrophy  of  the  disk  is  commonly  present 
after  severe  retinitis. 

6.  Pigmentation. — Black  spots  of  pigment  mark  the  situation  of 
former  retinal  hemorrhages.  Pigment  in  the  retina,  like  hemorrhages, 
although  in  many  instances  a  sequence  of  retinitis,  is  of  itself  not  neces- 
sarily a  symptom  of  inflammation  of  this  membrane. 

The  di  erence  between  pigment  in  the  retina  and  in  the  choroid 
has  been  described  on  page  373. 

7.  Atrophy  of  the  Retina. — This,  like  atrophy  of  the  choroid,  may 
indicate  a  former  hemorrhage  or  an  area  of  inflammation.  All  the 
retinal  layers,  as  well  as  the  choroid,  may  be  involved,  exposing  a 
white  patch  of  sclera  (atrophic  choroidoretinitis) ,  or  only  the  superficial 
layers  may  be  affected,  and  the  spot  may  be  marked  bj-  a  permanent 
whitish  or  yellowish  opacity.  Contraction  of  the  vessels  and  white 
tissue  along  their  coats  are  often  seen  after  retinitis. 

In  addition  to  the  ophthalmoscopic  signs  there  are : 

1.  Change  in  Visual  Acute7iess. — Central  vision  is  diminished  in 
direct  proportion  to  the  severity  of  the  case  and  the  situation  of  the 
inflammatory  action. 

2.  Change  in  the  Field  of  Vision. — This  may  be  irregularly  or  con- 
centrically contracted,  or  scotomas  may  appear  in  its  center. 

3.  Distortion  of  Vision. — This  occurs  under  several  forms:  (a)  Ob- 
jects appear  to  be  reduced  in  size  if  the  retinal  elements  are  spread 
apart  (micropsia);  (b)  objects  appear  to  be  increased  in  size  if  the 
retinal  elements  are  crowded  together  (macropsia) ;  (c)  objects  appear 
to  undergo  change  in  their  contour  or  shape  (metamorphopsia) .  Ver- 
tically placed  parallel  lines,  on  the  one  hand,  appear  to  be  bulged  out- 
ward, and,  on  the  other,  to  be  bent  inward.  Fine  parallel  lines  may 
appear  wavy  to  a  normal  eye.  Retinal  metamorphopsia  is  often 
associated  with  a  scotoma. 

4.  Pain  and  Photophobia. — i^cute  pain  is  almost  always  absent, 
even  in  violent  forms  of  retinal  inflammation;  indeed,  it  is  much  more 
likely  to  be  present  in  the  less  pronounced  grades. 

30 


466  DISEASES    OF   THE    RETINA 

Usually  the  sensation  is  one  of  discomfort  rather  than  of  actual 
pain.  Photophobia  may  or  may  not  be  present.  It  is  never  a  marked 
sign,  although  comfort  ensues  from  the  use  of  tinted  glasses. 

Diagnosis. — This  depends  upon  the  essential  symptom  of  the  dis- 
ease— opacity  or  loss  of  transparency  in  the  retina.  All  the  other 
symptoms  which  may  be  present — exudation,  hemorrhages,  pigmenta- 
tion, and  atrophy — help  to  make  up  the  clinical  characteristics  of  the 
various  types,  but  in  themselves  are  not  diagnostic  of  inflammation 
of  this  membrane. 

Much  diagnostic  aid  is  obtained  by  noting  the  effect  of  the  disease 
upon  vision,  especially  under  the  influence  of  diminished  illumination, 
and  if  acuteness  of  sight  fails  quite  out  of  proportion  to  the  amount 
of  the  light  reduction,  th(>  student  should  at  once  l)e  upon  his  guard. 
Investigation  of  the  light-sense  in  the  manner  already  described  (see 
page  67)  is  important.  If  the  coarse  changes  detailed  in  the  general 
symptom-grouping  are  present,  the  picture  is  readily  interpreted. 

Course  and  Complications. — The  course  of  a  retinitis,  like 
any  other  inflammation,  ma}-  be  acute  or  chronic,  and  its  progress 
of  long  or  short  duration.  When  the  retina  and  choroid  are  simul- 
taneously inflamed,  a  common  complication  is  change  in  the  vitreous 
(vitreous  opacities),  and  an  almost  constant  association  is  inflammation 
of  the  optic  papilla,  leading  to  atrophy  in  prolonged  cases  (retinitic 
atrophy) . 

Prognosis. — This  may  be  favorable,  grave,  or  positively  fatal,  de- 
pending upon  the  extent  of  the  inflammation,  its  situation  in  the  inner 
or  outer  layers  of  the  retina,  and  the  cause.  Before  giving  a  prognosis 
the  surgeon  must  always  attempt  to  estimate  the  extent  of  the  perma- 
nent disability  which  is  likely  to  remain  in  the  form  of  atrophy  of  the 
membrane  or  secondary  changes  in  the  papilla.  Other  things  being 
equal,  the  prognosis  of  syphilitic  retinitis  is  the  most  favorable. 

Treatment. — This,  in  general  terms,  demands  perfect  rest  for  the 
inflamed  organ,  and  therefore  atropin  mydriasis  is  often  desirable.  In 
sthenic  cases,  in  the  early  stages,  blood-letting  from  the  temple  has  been 
recommended. 

The  remedies  most  likeh'  to  afford  relief  are  the  various  forms  of 
mercury,  iodid  and  bromitl  of  potassium,  pilocarpin,  and  electric-cabi- 
net diaphoresis  and  Turkish  baths.  Special  methods  of  treatment  are 
reserved  for  the  sections  devoted  to  the  several  clinical  varieties. 

Types  of  Retinitis. — As  an  introduction  to  the  special  varieties 
of  retinitis  which  will  presently  be  considered,  it  serves  a  useful  clinical 
purpose  to  refer  lo  two  types  of  retinitis  formerly  deseribed  under  the 
names  serous  and  parcnchipnatous  retinitis.  The  lirst  type,  also  called 
retiinlis  simplex,  diJlfusc  retinitis,  and  edema  of  the  retina,  is  a  condition 
characterized  by  an  infiltration,  especially  of  the  nerve-fii»er  anil  gang- 
lionic layer  of  the  retina,  causing  op;icit\',  (ogcllicr  with  hypcrcMU.M, 
most  marked  in  the  veins. 

The  opacity  varies  from  a  delicate  veiling  to  a  dccitlcd  gr;»y-white 
opacity,  most  noticeable  around  the  nerve-head,  the  margins  of  which 


SYPHILITIC    RETINITIS    OR    CHORIORETINITIS  467 

are  veiled  or  hidden.  From  this  point  the  grayish  opacity  shades  out 
into  the  surrounding  retina.  The  disk  is  not  necessarily  swollen:  it 
may  be  simply  hidden  bj^  the  infiltrated  tissue,  or,  if  this  is  not 
marked,  it  is  very  red  and  its  edges  obscured  by  the  radiation  of 
finely  injected  capillaries  from  its  margins.  The  veins  are  dark,  fuller 
than  normal,  tortuous,  and  often  partly  covered  by  the  swollen  tissue; 
the  arteries  are  not  much  changed  in  size,  unless  perchance  they  vasiy  be 
reduced  in  caliber  by  compression.  Hemorrhages  are  rare,  and  exuda- 
tions in  the  macular  region  are  uncommon. 

There  are  no  external  signs  of  this  form  of  inflammation.  Both 
direct  and  indirect  vision  are  affected,  the  former  being  "foggy,"  the 
latter  concentricalh'  contracted. 

The  second  type,  also  called  deep  retinitis,  includes  those  forms  of 
retinitis  in  which,  in  addition  to  edematous  infiltration,  opacity  of  the 
retina,  and  venous  hyperemia,  there  are  pronounced  cellular  infiltra- 
tion and  structural  change,  leading  finally  to  atrophy  of  the  elements. 

Exudations  of  j^ellowish  or  gray  color  are  visible,  occurring  in 
patches  throughout  the  eye-ground,  and  often  localized  in  a  charac- 
teristic manner  in  the  macula.  Small  hemorrhages  are  commonly 
present,  and  the  morbid  processes  may  attack  the  sheaths  of  the  ves- 
sels, causing  thickening  and  hypertrophy. 

There  are  no  diagnostic  exterior  ocular  manifestations.  Deeply 
seated  pain  of  a  dull,  aching  character  may  be  present.  Vision  is 
often  much  disturbed,  varying  from  a  mere  fogginess  of  the  outlines  of 
objects  to  an  almost  absolute  loss  of  sight.  Contraction  of  the  field 
of  vision  and  positive  scotomas  are  demonstrable,  and  the  phenomena  of 
distortion  of  objects  are  apparent.  The  disease  may  be  circum- 
scribed or  diffuse,  and  localized  in  the  external  or  internal  layers,  or 
affect  both  of  these  and  also  involve  the  choroid. 

The  prognosis  of  the  second  variety  is  always  grave,  and  although 
in  certain  cases  absorption  of  the  products  is  possible,  compression  and 
atrophy  of  the  nervous  elements  must  result  in  most  instances.  Inde- 
pendenth^  of  the  fact  that  so-called  serous  retinitis  may  be  the  initial 
change  of  other  forms  presently  to  be  described,  it  has  been  ascribed 
to  cold,  to  undue  light  and  heat,  to  toxins,  infections,  and  to  the  in- 
fluence of  refractive  error  in  eyes  worked  under  the  disadvantage  of 
imperfect  illumination.  The  other  type  depends,  as  a  rule,  upon  va- 
rious constitutional  disorders,  or  occurs  in  association  with  other  dis- 
eases of  the  eye. 

Partaking  of  the  nature  of  one  or  the  other  of  these  forms  there 
are  certain  clinical  t3'pes: 

Syphilitic  Retinitis  or  Chorioretinitis. — The  syphilitic  forms 
of  retinal  inflammation  have  been  divided  by  Alexander  into:  (1) 
Choroidoretinitis;  (2)  simple  syphilitic  retinitis;  (3)  retinitis  with  exuda- 
tions; (4)  retinitis  with  hemorrhages;  and  (5)  central  relapsing  retinitis. 

The  first  form,  that  is,  diffuse  chorioretinitis,  first  described  by  Jacob- 
son  and  later  by  Forster,  is  really  a  disease  of  the  choroid,  and  the 
pathologic    changes  of  cellular  infiltration,  exudation,  atrophy,  and 


468 


DISEASES    OF    THE    RETINA 


proliferation  of  the  pigment  epithelium  are  found  in  the  choroid,  be- 
tween the  choroid  and  retina,  and  in  the  adjacent  retinal  layers.  There 
may  be  changes  in  the  retinal  vessels — that  is.  a  syphilitic  endorteritis. 
The  pigment  changes  are  produced  by  wandering  and  proliferation 
of  the  letinal  i)ignient.  The  choroid  is  markedly  altered;  sometimes 
the  choriocai)illaris  completely  disappears.  In  other  words,  the  reti- 
nitis does  not  depend  exclusively  upon  a  choroitlitis,  nor  does  tb.e 
contrary  relationship  hold  good. 

The  following  signs  are  visible:  Opacity  of  th(^  vitreous,  especially 
in  the  i)osterior  portion,  which  resolves  itself  into  fine  points  or  dust- 
like particles,  and  stretches  out  to  the  pcn-iphery  like  a  cloud;  loss  of 
transparency  of  the  retina  surrounding  the  n(>rve-h('ad.  which  may  be 


lie.   200.— Syphilitic  retinitis. 

uii(lul>'  liypcrcinic,  and  on  account  of  the  line  opacitx'  in  the  vitiTctus 
may  give  the  impression  that  it  is  swoIKmi;  munerous  yellowish  or  white 
spots  of  exudation  bounded  by  pigment  beneath  the  V(^ss(>ls  of  the 
retina  in  the  periphery  of  tiic  eye-grounds,  and  white  spots  in  the 
macula  present  in  fully  one-tliiid  of  the  cas(>s  (Fcirster);  and,  finally, 
participation  of  the  iiis  and  posterior  lay(>r  of  the  cornea  whicii  is 
a  not  infre(iuent  complication  (in  onc-si\tli  to  oiic-ciglith  of  the  ca.'^es 
[IgersheimerJ). 

"^rhe  siihjcctit'e  synii)tonis  ;iic:  I  )('pi((iat  ion  of  ccntnd  vision,  very 
marked  in  the  later  stages;  markedly  delayed  retinal  adaptation,  night- 
blindness  and  great  lessening  of  visual  acuteness  under  weak  illuniina- 
tion;  irregular  and  concentric  cont  i;ict  ion  of  tlir  \isual   lii'M  ami  the 


SYPHILITIC    RETINITIS    OR    CHORIORETINITIS  469 

formation  of  ring  scotomas,  sometimes  complete  and  sometimes  incom- 
plete, as  well  as  scotomas  in  the  center  of  the  field;  and  sector  defects 
in  the  periphery  and  shimmerings,  dancing  spots  and  circles  (photop- 
sias),  and  distortion  of  objects  in  the  form  of  micropsia  and  meta- 
morphopsia  due  to  separation  of  the  rods  and  cones  by  the  effusion. 

In  the  second  form  there  appears  to  be  a  more  definite  localization 
of  the  disease  in  the  retina,  particularly  its  inner  layers,  and  this 
tissue  is,  as  Schobl  expresses  it,  first  selected  by  the  syphilitic  poison. 
The  ophthalmoscope  reveals  a  gray  opacity  surrounding  the  nerve 
entrance  and  stretching  out  in  lines  along  the  vessels;  the  papilla  is  dis- 
colored, cloudy,  and  has  been  compared  to  a  yellowish-red,  oval  body 
seen  through  a  covering  of  fog.  The  veins  are  darker  than  normal;  the 
arteries  usually  are  not  materially  changed.  .Although  the  participa- 
tion of  the  choroid  in  these  processes  is  the  rule,  there  is  no  doubt  that 
a  pure  syphilitic  retinitis  can  develop  in  the  inner  layer  of  the  retina, 
independent  of  the  choroid.  Late  changes  which  occur  in  syphilitic 
chorio-retinitis  and  retinitis  are:  atrophy  of  the  disk  {retinitic  atrophy), 
pigmented  chorio-retinitis  in  the  variously  shaped  pigment  deposits, 
not,  however,  specially  disposed  along  the  vessels  and  occasionally 
posterior  cortical  cataract. 

Other  objective  symptoms  in  syphilitic  chorio-retinal  disease  are 
floating  vitreous  opacities,  exudations  along  the  lines  of  the  vessels 
{retinitis  ivith  exudations,  perivasculitis),  and  extravasations  of  blood, 
usually  round  in  shape,  attributed  to  disease  of  the  vessel  walls 
(endarteritis)  or  to  the  formation  of  thrombi  {retinitis  with  hemorrhage) . 
Hemorrhages  in  syphilitic  retinitis,  however,  are  of  comparatively 
uncommon  occurrence.     Preretinal  hemorrhages  have  been  observed. 

.A.ccording  to  Haab,  syphilitic  endarteritis  is  a  comparatively  rare 
disease,  and  may  present  the  following  lesions:  Visible  opacity  of  the 
walls  of  the  arteries  and  rareh''  of  the  veins;  almost  invisible  disease 
of  the  vessel  walls,  manifesting  itself,  as  in  senile  sclerosis,  by  a  nar- 
rowing of  the  blood-columns,  and  sometimes  associated  with  extrava- 
sations of  blood;  an  opacity  corresponding  to  that  caused  by  an 
obstruction  of  the  central  artery  or  one  of  its  branches,  and  appearing 
as  a  gray-white  or  a  milky  area,  with  ill-defined  edges,  in  which  at 
times  considerable  hemorrhage  may  take  place;  and  groups  of  circum- 
scribed white  patches  somewhat  resembling  those  seen  in  albuminuria. 

In  its  late  stages  sj^philitic  chorio-retinitis  may  be  elaborate.  Thus 
large  atrophic  areas  edged  with  pigment,  may  be  evident  between  which 
are  smaller  disseminated  pigment  spots,  associated  with  marked  vas- 
cular changes,  the  vessels  being  sheathed  in  white  lines  or  converted 
into  white  cords. 

Date  of  Occurrence. — In  the  acquired  form  of  the  disease  it 
appears  from  one  to  two  years  after  infection,  sometimes  as  early  as 
the  sixth  month,  and  is  found  in  about  8  per  cent,  of  the  cases  (Alex- 
ander). One  eye  alone  may  be  affected,  but  usually  after  several 
months  the  second  eye  is  also  involved.  It  is  more  common  between 
the  third  and  fourth  decade  of  life  than  at  other  periods. 


470  DISEASES    OF   THE    KETINA 

True  retinitis  must  not  be  confounded  with  the  so-called  "retinal 
irritation"  commonly  seen  in  association  with  iritis,  and  the  symptoms 
of  which  have  been  described  (page  461).  Retinitis,  however,  may 
accompany  or  follow  iritis. 

Course  and  Prognosis. — Although  the  onset  of  syphilitic  chorio- 
retinitis may  be  sudden,  the  course  is  essentially  chronic. 

The  pro(jtiof>is  largely  depends  ui)on  the  stage  at  which  treatment  is 
begun  and  the  vigor  of  the  measures  employed.  Delayed  or  neglected 
treatment  may  lead  to  the  grave  consequences  of  extensive  atrophic 
choroiditis,  pigmentary  degeneration  in  the  retina,  and  atrophy  of  the 
optic  disk.  Even  in  favorable  circumstances  improvement  may  be 
temporary  and  many  stubborn  relapses  occur.  An  attack  of  iritis 
may  complicate  or  usher  in  a  relapse. 

Treatment. — The  same  constitutional  measures  recommended  in 
the  treatment  of  syphilitic  iritis  (see  page  335)  are  indicated,  anil,  in  so 
far  as  mercurials  are  concerned,  should  be  vigorously  employed.  Con- 
cerning the  value  of  salvarsan,  or  arsphenamin,  in  syphilitic  retinitis, 
it  may  be  said  that  successes  have  been  reported  even  in  the  presence 
of  decided  endarteritis,  and  in  the  author's  experience  the  use  of  this 
remedy  in  the  manner  already  described  has  been  followed  by 
admirable  results.  It  has  no  evil  effect  on  the  retina.  Usually  a 
mydriatic  is  advisable,  and  in  any  event  dark  glasses  may  be  worn. 

Central  relapsing  retinitis  {retinitis  macularis)  belongs  to  the  late 
manifestations  of  syphilis,  and  appears  in  the  form  of  a  gray  or  yellow- 
area  in  the  macula,  or  as  numerous  small  yellow  or  yellowish-white 
spots  and  pigment  dots,  or  as  a  diffuse  opacity  of  this  region.  The 
papilla  and  its  surroundings  are  unaffected.  It  is  a  rare  form  of 
syphilitic  retinitis,  stubborn  in  its  character,  and  prone  to  relapse. 

Hereditary  Syphilitic  Choroidoretinitis. — Various  tyi)es  of  he- 
reditary syphilitic  affections  of  the  retina  and  choroid  occur,  antl  they 
have  been  particularly  well  described  antl  depicted  by  Haab  and  Sidler- 
Huguenin.  Whether  the  primary  seat  of  the  disease  in  these  cases  is  in 
the  retina  or  in  the  choroid  has  not,  in  Haab's  opinion,  been  definitely 
settled.  According  to  these  authors,  some  of  the  following  types  may 
be  encountered:  (1)  The  periphery  of  the  eye-ground  jiresents  a  some- 
what leaden  color  and  contains  black  circular  and  triangular  patches  of 
pigment.  The  remainder  of  the  fundus  is  thickly  covered  with  reddish- 
yellow  spots  placed  upon  a  dotted  brownish-black  surface.  Occa- 
sionally these  lesions  are  not  extensive  and  cover  only  certain  portions 
of  the  fundus,  especially  the  periphery.  (2)  Chiefly  in  the  periph(>ry 
of  the  eye-ground  roundish  black  foci  of  pigment,  discrete  and  con- 
fluent, are  evident,  interspersed  witii  linear  and  cinulai-  y(>llowish 
patches.  The  lesions  are  not  infictiuent ly  seen  after  the  sul)sidence  of 
interstitial  keratitis.  (3)  In  pl.ace  of  gray  and  black  lesions,  whitish 
circular  or  confluent  patches  may  be  found  in  ilie  periphery  of  the 
fundus.  Som(>times  these  types  are  mixed,  and  in  some  severe  cases 
there  are  coarse  choroidoretinitis,  diseased  retinal  vessels,  and  atrophy 
of  the  optic  neiN'e.     Tlieic  ni;i\-  lie  diiniiiulion  of  central  vision,  con- 


METASTATIC    RETINITIS  471 

traction  of  the  field  of  vision,  and  night-blindness,  symptoms  which 
are  absent  in  mild  manifestations  of  the  disease.  Other  types, of 
chorio-retinitis  in  hereditary  syphilis  are:  chorio-retinitis  circum- 
papillaris,  in  which  for  a  wide  space  around  the  nerve  head  are  arranged 
small  yellowish-white  lesions  (Igersheimer) ;  chorio-retinitis  with  ex- 
tensive perivasculitis  and  areas  of  disseminated  pigmentation,  cloud- 
ing of  the  disc  by  an  exudation,  bluish  white  or  gray  red  in  color 
which  extends  from  it,  and  light  colored  small  lesions  in  the  periphery 
(Knapp,  Hirschberg).  The  treatment  of  the  chorio-retinal  lesions  of 
hereditary  sj'philis  does  not  differ  from  that  suggested  in  the  acquired 
forms  of  the  disease,  except  that  the  author  cannot   from  his  own 


Fin.  207. — Appearances  of  the  eye-ground  in  hereditary  syphilis  (from  a  patient  in  the 

University  Hospital) . 

experience,  testify  as  to  the  value  of  salvarsan  or  its  equivalent.  He 
has  usually  employed  mercury  and  the  iodids. 

Metastatic  Retinitis  {Septic  Retinitis  of  Roth). — This  term  has 
been  applied  to  an  affection  especially  seen  in  surgical  pyemia  and  puer- 
peral septicemia,  and  is  characterized  by  small,  circumscribed  w^hite 
spots  near  the  papilla  and  in  the  macular  region.  Usualty  both  eyes 
are  involved,  and  numerous  small  hemorrhages  may  be  seen.  These 
spots  are  due  to  fatty  degeneration  of  the  capillaries  and  infiltration  of 
the  retinal  fibers,  caused  by  the  infectious  emboli  in  the  vessels. 
Micro-organisms  have  been  demonstrated  in  the  lesions  and  in  the 
retinal  vessels. 

The  spread  of  the  inflammation  to  the  uveal  tract  and  the  relation 


472  DISEASES    OF   THE    RETINA 

of  this  condition  to  purulent  tnctastatic  ophthalmitis  (choroiditis)  has 
been  described  on  page  386.  This  condition  is  also  sometimes  called 
embolic  panophthalmitis  or  endogenous  ophthalmitis. 

An  independent  or  primary  suppurative  retinitis  may  be  caused  by 
injury,  that  is,  by  a  penctratinu;  foreign  l)ody  (see  also  j)age  319). 

Treatment. — The  prognosis  and  treatment  of  suppurative  retinitis 
does  not  materially  differ  from  that  recorded  in  connection  with  meta- 
static ophthalmitis.  Occasional  recoveries  are  recorded  with  preserva- 
tion of  eyesight. 

Hemorrhagic  Retinitis. — The  presence  of  hemorrhages  in  the  ret- 
ina does  not  impl}'  the  coexistence  of  retinitis;  only  if  signs  of  in- 
flammation are  added  is  the  term  "hemorrhagic  retinitis"  justified. 

In  a  typical  case  the  appearances  are  as  follows:  Swelling  of  the 
papilla,  its  edges  being  cloudetl  or  hidden  by  an  opatjue  infiltration 
of  the  surrounding  retina;  darkly  tortuous  and  distended  veins,  but 
small  arteries;  and  numerous  hemorrhages,  linear,  flame  shaped, 
irregular,  or  round  in  shape. 

The  size,  number,  diffusion,  and  localization  of  the  hemorrhages 
vary.  Thus,  they  may  be  everywhere  throughout  the  eye-grouiul,  or 
grouped,  especially  in  the  macular  region  or  around  the  papilla.  If 
white  spots  are  present  as  the  result  of  degeneration  after  absorption  of 
the  blood,  the  appearances  may  closely  resemble  those  seen  in  so-called 
albuminuric  retinitis,  which,  indeed,  may  be  one  of  the  types  of 
hemonhagic  retinitis. 

Causes. — Hemorrhagic  retinitis  occurs  with  diseases  of  the  heart 
and  of  the  blood-vessels — e.  g.,  hypertrophy,  aneurysm,  and  end- 
arteritis; in  suppressed  menstruation;  at  the  climacteric;  and  in  a 
variety  of  general  and  local  diseases,  sometimes  jjresenting  types  pres- 
ently to  l)e  described  under  special  clinical  designations.  More  rarely, 
retinitis  with  hemorrhages  is  caused  by  secondary  syphilis. 

The  hemorrhages  may  be  due  to  rupture  of  retinal  vessels  whose 
coats  have  become  degeneratetl — in  other  words,  they  depend  upon 
endarteritis;  but  recent  investigationsshow  that  in  many  cases,  although 
the  arteries  may  be  diseased,  there  is  even  more  exteiisive  change  in 
venous  coats,  and  there  may  be  thrombosis  of  the  central  vein.  The 
di.sease  is  often  confined  to  one  eye.  The  connect  ion  bet  ween  degenera- 
tion of  the  blood-vessels  and  chronic  inllaniniation  of  the  inner  layers 
of  the  retina  is  an  intimate  one.  To  all  inllanunation  of  the  layers  of 
the  retina  under  such  contlitions  the  term  angiupathic  retinitis  is  applied 
by  Wildbrand  and  Saenger.  (For  further  consideration  of  this  subject, 
see  neiiionhage  in  the  Retina,  p.  404.) 

Prognosis.  This  is  unfavoral)le  because  the  ocular  condition  may 
indicate  a  grave  vascular  or  cardiac  malady,  and  may  be  the  forerumier 
of  extravasations  in  vital  centers.  Sight  may  be  seriously  impaired. 
Secondary  changes  in  the  retina  and  optic  nerve  aic  likely  to  follow; 
glauc<iiiia  frecpiently  results. 

Treatment.  The  therapeutic  nieasuics  must  be  governed  l»y  the 
g(>neral    c()ii(lition.      !•'.   \{.  ("ross  reconinieiids  sulx'onjuiict  ival   blood- 


I 


ALBUMINURIC    RETINITIS  473 

letting,  and  wet-cupping  the  temple  has  been  advised.  Often  mercury, 
iodid  of  potassium,  and  iodid  of  sodium  are  indicated,  with  or  without 
cardiac  sedatives,  and  diaphoresis  may  be  required. 

Albuminuric  Retinitis  {Renal  Retinitis  Papilloretinitis;  Retinitis 
of  Bright' s  Disease). — Symptoms. — In  a  typical  case,  beginning  in  the 
macula  or  its  immediate  neighborhood,  and  continuing  to  be  most 
numerous  in  this  region,  variously  shaped  and  placed  white  spots  appear. 
These  at  first  may  be  small,  discrete,  and  sharply  separated,  but  later, 
or  under  other  conditions,' they  form  a  somewhat  star-shaped  figure,  the 
rays  of  which  surround  the  fovea;  but  for  the  most  part  do  not  involve 
it.  Occasionally,  instead  of  a  stellate  arrangement,  the  white  spots 
and  lines,  somewhat  radially  placed  like  spokes  in  a  wheel,  affect  this 
neighborhood  in  part,  but  do  not  completely  encircle  it. 

At  some  distance  from  the  papilla,  and  often  surrounding  it,  larger 
yellowish-white  or  white  spots  are  seen,  which  may  coalesce  and  form  a 
ring-shaped  zone  around  the  nerve-head  broader  than  its  own  diameter. 
This  striking,  wide  white  area  has  been  compared  to  snow,  and  desig- 
nated "the  snowbank  appearance  of  the  retina." 

Other  features,  but,mnlike  the  white  spots,  having  no  pathogno- 
monic appearances,  are  the  hemorrhages.  They  may  be  linear,  flame 
shaped,  or  round,  or  mere  flecks  scattered  here  and  there,  and  found 
with  difficulty,  or  they  constitute  large,  dark-red  extravasations.  More- 
over, they  are  not  constant  like  the  white  spots,  but  at  times  disappear, 
leaving  white  marks  which  denote  their  former  situation.  Sometimes 
they  occur  in  great  numbers,  like  fresh  explosions.  To  a  certain  extent 
they  are  indications  of  the  violence  of  the  disease. 

The  blood-vessels  may  run  over  the  white  plaques,  or  may  be  buried 
in  the  swollen  retina.  Sometimes  a  vessel  disappears  beneath  the  infil- 
tration, to  reappear  at  some  distance  beyond.  The  veins  are  dark  and 
often  tortuous;  the  arteries,  as  in  other  forms  of  retinitis,  are  not  mate- 
rially altered  in  size.  In  the  later  stages  the  vessels  exhibit  lack  of 
transparency  of  their  walls,  in  the  form  of  white  tissue  along  the  sheaths, 
or  they  are  actually  converted  into  white  strings. 

Finally,  the  optic  papilla  and  its  immediate  surroundings  may  be 
intensely  hyperemic,  or  a  swelling  of  the  nerve-head  occurs,  quite 
indistinguishable  from  that  of  optic  neuritis,  or  choked  disk,  as  it  is  seen 
in  tumor  of  the  brain.  In  any  circumstances  the  edge  of  the  papilla  is 
clouded,  but  not  necessarily  swollen,  the  surrounding  retina  finely 
clouded,  and  traversed  with  numerous  radiating  injected  lines,  like 
those  described  in  other  types  of  retinitis.  Quite  commonly  the 
changes  in  the  papilla  directly  join  the  band  of  fatty  infiltration  already 
described,  surrounding  the  end  of  the  optic  nerve. 

The  chief,  in  fact  the  only,  subjective  symptom  is  depreciation  of 
vision,  which  may  vary  from  a  slight  and  gradual  impairment  to  com- 
plete blindness.  It  is  a  well-known  fact  that  Bright's  disease  is  often 
discovered  by  an  ophthalmoscopic  examination,  the  patient  being 
ignorant  of  the  fact  that  he  is  the  subject  of  serious  organic  malady. 
The  visual  field  may  be  altered  according  to  the  situation  of  the  retinal 


474  DISEASES    OF   THE    RETINA 

lesions,  and  may  contain  blue-blind  areas.  According  to  Gerhardt, 
blue-blindness  may  be  a  sign  of  contracted  kidney,  and  Simon  main- 
tains that  violet-blindness  is  not  uncommon  in  connection  with  all)U- 
minuric  retinitis. 

Forms  of  the  Disease. — Two  varieties  have  been  recognized — an 
inflammatory  or  exudative  and  a  degenerative  type.  Often  the  two  are 
combined. 

The  former  may  be  present  as  violent  neuroretinitis  from  the  begin- 
ning, or  it  may  start  as  a  degenerative  type  and  develop  inflammatory 
activity.  The  latter  begins  without  inflammatory  changes,  the  white 
spots  are  small,  often  quite  minute,  and  separated  by  comparatively 
normal  areas,  and  the  hemorrhages,  if  present,  are  inconspicuous,  being 
confined  largely  to  the  nerve-fiber  layer.  The  arteries  are  sclerotic,  the 
veins  dark,  and  the  disk,  in  the  early  stages,  blurred  and  indistinct,  but 
there  is  no  peripapillary'  zone  of  white  exudation  and  no  macular  figure. 
If  hemorrhages  are  the  most  conspicuous  feature  of  the  disease,  the  term 
hemorrhagic  is  applied;  if  the  changes  are  almost  wholly,  confined  to 
the  optic  papilla,  the  neuritic  or  papiUitic  type  is  present.  By  some 
systematic  writers  a  sharp  distinction  has  been  drawn  between 
degenerative  and  exudative  albuminuric  retinitis.  The  former  is 
associated  with  granular  kidney  and  the  latter  with  parenchymatous 
nephritis,  that  is,  the  exudative  variety  is  inflammatory  and  probably 
toxic  in  origin;  the  degenerative  depends  on  vascular  changes  (see  page 
497). 

Often  small  hemorrhages  and  comparatively  insignificant  dots  in 
the  macula  may  be  the  signs  of  renal  retinitis,  and  consetiuiMitly  of  renal 
disease.  Indeed,  the  so-called  typical  renal  retinitis  is  not  so  frequently 
encountered  as  the  less  elaborately  produced  lesions  of  this  affection. 
Among  early  signs  of  renal  retinitis  are  changes  in  the  capillary  circula- 
tion and  dilatation  and  tortuosity  of  the  small  vessels  arouncl  the 
macula,  while  the  nerve-head  assumes  a  congestetl.  brick-red  color.  In 
every  case  of  retinal  disease  the  urine  should  be  frequently  and  thor- 
oughly examined. 

Causes,  Date  of  Occurrence,  and  Frequency. — WliiU*  in  general 
terms  Hriglil's  disease  is  the  cause  of  the  retinitis  which  Ix^ars  its  name, 
it  most  frequently  occurs  with  chronic  interstitial  nepiuitis.  It  may 
also  be  caused  by  chronic  parenchymatous  nephritis,  especially  in  the 
so-called  inflammatory  form.  Naturally,  the  secondary  contracted 
kidney,  which  is  a  secjuence  of  large  white  kidney,  may  l»t>  a.ssociated 
witli  retinitis,  and  this  is  also  true  of  amyloid  (Hsease  of  tlie  ki(liu\v. 
The  retinitis  occurring  with  pregnancy  is  usually  ascribed  to  albu- 
minuria, but  is  probal>ly  due  to  the  same  substances  which  cause  the  albu- 
minuria, tin;  eclampsia,  vomiting,  etc.,  namely,  toxemic  products  in 
tiie  circuhitioii.  iietinitis  may  arise  in  the  course  of  a  si-arlatinal 
nepluilis.  Ill  ^iciieral  terms  it  may  be  stateil  that  while  renal  reti- 
nitis is  the  (julcdiiie  <»f  ki(biey  (hsease  which  causes  albuminuria,  it  is 
not  caused  by  the  ;illiuiiicii. 

Usually  botli  eves  arc  iii\ oK cd,  l)iit  itiiilatirid  (dhuminuric  retinitis 


Plate  IV. 


Albuminuric  retinitis ;  star-shaped  figure  in  the  macula  ;  the  cir- 
culation in  the  distended  veins  impeded  where  the  latter  are  crossed 
by  the  arteries  which  are  undergoing  sclerotic  changes. 


ALBUMINURIC    RETINITIS  475 

is  not  a  rarity  (Knies),  a  certain  percentage  of  cases  maintaining  retinal 
lesions  in  one  eye  alone  until  death.  In  another  large  percentage  of 
cases  the  unilateral  character  of  the  affection  is  temporary,  both  eyes 
ultimately  becoming  affected.  In  general  terms  it  is  probable  that  the 
renal  disease  must  be  present  for  some  months  before  retinal  lesions 
appear.  The  age  at  which  patients  are  attacked  is  usually  stated  to 
vary  from  thirty  to  sixty,  the  most  prolific  single  decade,  according  to 
Nettleship,  being  from  fifty  to  sixty.  It  is  comparative!}'  rare  before 
the  twenty-fifth  year,  but  children  and  young  persons  are  not  exempt. 

About  twice  as  many  cases  of  renal  retinitis  occur  in  men  as  in 
women.  If  there  is  decided  hyaline  thickening  of  the  retinal  arteries, 
an  earh'  stage  of  granular  kidnej-  ma}'  be  suspected,  especially  if  the 
patient  is  comparatively  young  (Nettleship).  The  recorded  percent- 
age of  retinitis  in  renal  diseases  varies  from  9  to  33.  In  the  author's 
experience  fully  30  per  cent,  of  patients  with  chronic  Bright's  disease, 
as  he  has  examined  them  in  general  hospitals,  have  been  affected  by 
various  forms  of  retinitis,  but  if  these  statistics  should  include  not  only 
the  cases  of  so-called  typical  retinitis,  but  also  those  of  comparatively 
insignificant  lesions,  consisting  chiefl}'  of  alterations  in  the  walls  of  the 
retinal  vessels  and  blurring  of  the  disk,  this  percentage  would  be  con- 
siderably higher. 

Course,  Pathologic  Anatomy,  and  Prognosis. — The  course  of  typical 
renal  retinitis  has  been  divided  into  the  stage  of  hyperemia  of  the 
papilla,  opacity  of  the  retina,  and  hemorrhages;  the  stage  of  fatty 
degeneration;  and  the  stage  of  retrograde  metamorphosis  and  atrophy. 

The  white  spots  may  subside,  but  rarely  disappear  entirely,  the 
macular  changes  being  most  permanent.  Discoloration  and  atrophy  of 
the  papilla,  contraction  of  the  vessels  and  the  formation  of  white 
tissue  along  their  walls,  and  pigment  changes  in  the  retina  finally  result. 

The  pathologic  changes  are  found  chiefly  in  the  macular  region  and 
in  a  zone  surrounding  the  nerve.  The  retina  is  thickened  by  the  pres- 
ence of  the  so-called  inflammatory  edema  and  by  hypertrophy  of  its 
nervous  and  supporting  tissue.  The  glistening  spots  in  the  macular 
region  are  due  to  a  fatty  degeneration  of  the  exudation  and  of  the 
retinal  elements.  Their  star-shaped  arrangement  depends  upon  the 
oblique  direction  of  the  fibers  of  ]M tiller  in  this  position.  INIany  fatty 
granular  cells  and  deposits  of  coagulated  fibrin  are  seen,  particularly 
in  the  nuclear  laj'ers.  Hemorrhages  are  present,  but  not  necessarily 
a  pronounced  feature.  In  the  early  stages  the  vessels  show  thickening 
of  the  adventitia,  and  later  pronounced  hyaline  change  and  prolifera- 
tion of  the  lining  endothelium.  The  nerve  in  many  cases  is  swollen  by 
the  inflammatory  edema.  The  same  causes  which  originate  disease  of 
the  blood-vessels  of  the  kidnej'  originate  also  the  alterations  in  the 
retinal  vessels,  and  to  these  alterations  the  chief  role  must  be  ascribed 
in  causing  the  various  types  of  retinal  lesions.  Indeed,  some  authori- 
ties maintain  that  so-called  albuminuric  retinitis  is  entirely  the  out- 
come of  disturbances  in  the  circulation,  that  is,  depends  on  arterio-^and 
phlebosclerosis  and  their  sequels.     Sclerotic  changes  in  the  choroid 


476  DISEASES    OF    THE    RETINA 

vesssel  are  also  present.  Comparatively  recent  researches,  however, 
indicate  that  renal  retinitis,  althoujih  the  vascular  changes  may  not  be 
entirely  disregarded  in  an  etiologic  significance,  should  be  attributed 
to  toxic  material  elaborated  by  the  decomposition  of  kidney  sub- 
stance, which  toxin  possesses  selective  affinity  for  the  retinal  ti.ssues 
(Zur  Nedden). 

Complications. —  Detachment  of  the  retina,  hemorrhage  into  the 
vilreou.s.  enibulism  and  thrombosis  of  the  ves.sels,  extravasations  into 
the  choroid,  and  glaucoma  may  be  complications  of  this  aflfection. 
Detachment  of  the  retina  is  not  infrecjuent,  and  glaucoma  may  arise 
exactly  as  it  does  with  retinal  hemorrhages  and  retinal  angiosclerosis. 
According  to  R.  Foster  Moore  retinal  detachments  in  renal  retinitis 
may  be  flat  due  to  solid  exudation — fibrinous,  granular  or  hyalin,  or 
globular  due  to  accumulation  of  fluid.  Recovery  is  not  inconsistent 
with  this  type  of  retinal  detachment.  Retinal  detachment  was  also 
noted  in  the  retinitis  or  retinal  edema  which  was  frecjuently  observed 
in  association  with  trench  nephritis  during  the  past  war,  (Derby, 
Greenwood.) 

Prognosis. — The  prognosis,  so  far  as  vision  is  concerned,  depends 
upon  the  extent  of  the  lesions  and  of  the  involvement  of  the  macula. 
In  general  terms  it  is  unfavorable,  although  fair  vision  is  often  retained. 
Sometimes  the  exudations  practically^  disappear.  In  so  far  as  the  life 
of  the  patient  is  concerned,  albuminuric  retinitis  is  an  unfavorable 
symptom,  and  many  patients  die  within  two  years  after  its  detection, 
and  a  considerable  percentage  within  the  first  year  of  its  development. 
There  are,  however,  frequent  exceptions  to  the  rule,  and  the  records 
show  that  patients  have  lived  five,  seven,  and  even  a  greater  number 
of  years  after  the  retinal  lesions  have  appeared,  especially  if  they  have 
been  detected  early  and  suitable  treatment  has  l)een  instituteil. 

Albuminuric  Retinitis  in  Pregnancy. — While  the  occurrence  of 
albuminuria  during  pregnancy  is  not  uncommon,  varying,  according  to 
statistical  reports,  from  2  to  20  per  cent.,  involvement  of  the  optic 
nerve  and  retina,  in  the  form  of  a  neuroretinitis,  to  which  the  term 
albuminuric  retiniiis  of  pregnancy  is  usually  applied,  is  much  less  fre- 
quent. The  retinitis  in  this  condition  may  gradually  develop,  occurs 
most  frecjuently  in  primiparie,  ami  generally  in  the  seconil  half  of  preg- 
nancy; exceptionally  at  an  earli(>r  period.  The  ophthalmoscopic  signs 
of  this  retinitis  may  not  differ  from  those  which  ar(^  caused  l)y  other 
forms  of  Bright 's  diseuse,  :uh1,  in  general  terms,  there  is  a  wide-spread 
neuroretinitis  with  exudations  and  hemorrhages.  The  retinitis  of 
pregnancy  has  i)een  ascribed  to  a  nephritis  which  is  brought  al>out  by 
this  condition,  especially  a  fatty  degeneration  of  th(>  kidney  epithelium, 
and  also  to  toxemic  pioducts  in  the  circulation  (.1.  II.  l"'isher;  see  also 
page  475).  It  may  also  \)v  cau.sed  by  an  acute  lu^phritis  which  hiu^ 
develoiM'd  during  the  pregnant  period,  and  liy  an  exacerl>ation  of  a 
pre-existing  chi'oiiic  nephritis  during  the  same  |)eiio(l.  Retinal 
detachment  may  be  a  coniplical  iiig  condition;  it  ma\  sul>side  entirely 
with  the  (lisapj)earanc('  of  the  ictin.al  lesions. 


ALBUMINURIC    RETINITIS 


477 


In  the  albuminuric  retinitis  of  pregnancy  the  prognosis,  in  so  far  as  it 
concerns  the  vision  and  the  Hfe  of  the  patient,  depends  upon  the  dura- 
tion of  gestation.  With  the  termination  of  pregnancy  the  inflamma- 
tory deposits  (the  type  most  often  is  inflammatory)  may  subside  and 
good  vision  may  be  restored,  provided  the  process  has  not  continued^so 
long  that  the  secondary  changes  already  described  have  taken  place. 
For  this  reason  the  induction  of  premature  labor  has  been  recom- 
mended as  a  therapeutic  measure,  and  if  the  visual  disturbances  appear 
during  the  first  six  months  of  gestation  usually  the  pregnancy  should 
be  terminated  if  sight  is  to  be  saved. 

Diagnosis. — In  wide-spread  albuminuric  retinitis  the  changes. de- 
tailed in  the  SA^mptom-grouping  are  striking  and  in  a  sense  character- 


FiG.   208. — Albuminuric    retinitis   of   pregnancy.      Colored    patient   in    the    University 

Hospital. 

istic,  but  the  so-called  typical  cases  are  not  as  frequent  as  those  in 
which  the  lesions  are  not  so  evident,  and  the  significance  of  the  retinal 
disease  must  be  decided  by  general  examination.  Even  so-called 
"typical"  appearances  have  been  observed  in  infections — for  example, 
erysipelas  and  syphilis — independently  of  nephritis.  Thus,  Schieck 
has  investigated  a  certain  number  of  eyes  with  macular  changes  which 
were  regarded  as  characteristic  of  nephritis,  and  yet  the  evidence  of 
kidney  disease  was  lacking;  similar  observations  have  been  made  by 
Wildbrand  and  Saenger,  by  Parsons,  and  by  the  author. 

Neuroretinitis  from  intracranial  disease  may  simulate  this  affection, 
and  often  only  by  a  careful  study  of  the  urine  and  the  general  symp- 


478  DISEASES    OF   THE    RETINA 

toms  the  diagnosis  can  be  established  (see  also  page  528).  The  ques- 
tion becomes  still  more  complicated  if  allmminuria  is  associated  with 
brain  tumor. 

In  glycosuria  and  leukemia  somewhat  analogous  appearances  are 
found,  and  again,  an  examination  of  the  urine,  as  well  as  that  of  the 
blood,  may  be  necessary  before  reaching  a  diagnosis. 

The  white  spots  are  distinguished  from  plaques  of  choroidal  atrophy 
by  the  absence  of  pigment  heaping.  The  snowbank  appearances  differ 
from  retained  marrow  sheath  (see  page  516)  in  that  the  latter  stretches 
away  from  the  margin  of  the  disk,  usually  ending  in  a  fan-shaped 
border,  and  is  unaccompanied  by  the  changes  in  the  macula  or  by 
retinal  edema.  Fine  lesions  of  the  choroid  in  the  macular  region  may 
be  mistaken  for  somewhat  similar  retinal  changes;  but  they  are  more 
scattered,  more  yellow  in  color,  usually  unassociated  with  distinct 
loss  of  vision,  and  less  liable  to  assume  a  stellate  or  radial  appearance. 

It  is  evident  that  a  star  shaped  figure  in  the  macula  is  in  no  sense 
pathognomonic  of  renal  retinitis  and  it  may  arise  under  various  condi- 
tions and  as  the  result  of  diverse  factors.  It  may  be  the  sole  lesion 
or  there  may  be  an  associated  papillitis.  Such  a  lesion  may  arise, 
especially  in  young  persons  without  discoverable  cause,  or  be  due  to 
focal  infections  or  to  anemia  and  chlorosis.  In  one  case  reported  by 
the  author,  the  subject  of  the  affection  being  a  young  woman  with 
pronounced  chlorosis,  all  the  manifestations  disappeared  under  the 
influence  of  iron-therapy.  The  name  stellate  retinitis  is  applied  to 
this  condition. 

Treatment. — Local  measures  are  practically  of  no  avail.  The 
case  must  be  managed  on  the  general  principles  suited  to  the  form  of 
kidney  disease  which  is  present  and  the  patient  should  be  studied  and 
treated  in  conjunction  with  an  internist.  A  proper  remedy  in  most 
cases  is  iron,  usually  in  the  form  of  the  tincture,  and  often  ailvan- 
tageously  c(jmbined  with  bichlorid  o{  mercury.  Decapsulation  of  the 
kidney  has  been  tried  without  encouraging  success.  Harvey  Cushing 
has  recommended  cerebral  decompression,  because  he  believes  that 
increased  intracranial  tension  is  an  important  factor  in  the  develop- 
ment of  all)uniinuric  retinitis.  The  author's  single  experience  with 
this  operatif)n  in  these  circumstances  was  disastrous. 

Diabetic  Retinitis. — This  occurs  in  several  forms.  It  is  always 
bihitcnil,  but  both  eyes  may  not  be  affected  at  the  same  time. 

Ilirschberg  describes  two  varieties  of  diabetic  retinitis — an  cziuia- 
tivc  and  a  lioimrrhiujic  form.  In  some  cases  of  iliaVx'tic  retinitis,  cither 
witli  or  witiiout  licniorriiagc,  there  are  wide-spread  ari'as  of  yellowish- 
white  exudation  and  fatty  change,  and  these  lesions  may  arrange 
themselves  in  zone-like  areas,  above  or  below  the  macula,  resembling 
the  so-called  circinate  retinitis,  and  may  Ix^  nuussed  in  tiie  c(Mitral 
region  of  the  retina.  They  usually  are  late  manifest  at  ions  of  diabetes, 
and  are  seen  at  a  time  when  gangrene,  carbuncle,  hemiplegia,  and  other 
serious  complications  of  this  tlisorder  arise.  In  any  case  of  diabetes 
of  long  <luration  retinitis  is  seldom  absent,  although  it  may  sometimes 


DIABETIC    RETINITIS 


479 


be  difficult  to  find  the  lesions,  because  they  are  situated  in  the  periph- 
ery of  the  eye-ground.  This  is  especially  true  if  the  complication 
of  high  myopia,  or  cataractous  lens,  is  present. 

More  commonly  than  in  the  retinitis  of  albuminuria,  opacities  and 
hemorrhages  occur  in  the  vitreous  humor,  and  a  condition  analogous  to 
proliferating  retinitis  may  arise.  To  a  collection  of  small  white  spots 
and  hemorrhages  irregularly  arranged  in  the  macular  region  and  be- 
tween it  and  the  disk  the  name  central  punctate  diabetic  retinitis  has 
been  applied.  By  some  authors  this  appearance  is  considered  typical 
of  diabetes.  The  vital  prognosis  is  unfavorable,  but  not  so  grave  as  in 
albuminuric  retinitis.     Diabetes  and  chronic  nephritis  may  ,be  coin- 


FiG.  209. — Diabetic  retinitis;  extensive  white  exudations  in  the  macular  region. 


cident  and  complicate  the  ophthalmoscopic  picture;  so  also  a  diabetic 
subject  may  have  generalized  arteriosclerosis  with  the  retinal  lesions 
of  that  condition  predominating  or  present  to  the  exclusion  of  others 
dependent  on  the  metabolic  disorders  (see  also  page  551). 

To  a  striking  ophthalmoscopic  picture  characterized  by  a  very 
light  salmon  color  of  the  blood  in  the  retinal  arteries  and  veins,  which 
are  much  enlarged,  and  by  a  somewhat  light  color  of  the  general  fundus 
the  name  lipemia  retinalis  has  been  given  (Heyl) .  These  appearances 
are  ascribed  to  the  presence  of  fat  in  abnormal  amounts  in  the  blood." 
No  hemorrhages  or  exudations  develop;  in  this  respect  it  differs  from 
leukemic  retinitis.  It  is  apt  to  occur  in  young  diabetics  and  implies  a 
grave  prognosis. 


480  DISEASES    OF    THE    RETINA 

Treatment. — There  is  no  local  treatment  of  diabetic  retinitis.  The 
discovtM y  of  such  a  condition  may  lead  to  the  finding;  of  sugar  in  the 
urine,  but  more  commonly  the  patient  is  already  conscious  of  his  dis- 
ease and  is  under  medicinal  and  dietetic  treatment. 

Leukemic  Retinitis. — The  retinal  changes  seen  in  splenic  leuke- 
mia, to  which  variety  of  the  disease  they  are  almost  exclusively  con- 
fined, affect  both  eyes,  usually  one  more  than  its  fellow. 

The  most  important  ophthalmoscopic  appearances  are  slight  swell- 
ing of  the  papilla,  pallor  of  its  surface,  veiling  of  its  edges,  and  some 
opacity  of  the  retina,  especially  along  the  lines  of  the  vessels.  The 
latter  present  a  striking  appearance.  The  veins  are  broad,  distended, 
and  of  a  somewhat  rose-red  color;  the  arteries,  in  contrast,  narrow  and 
orange  yellow,  which  color  substitutes  the  ordinary  fiery  red  of  the 
choroid,  the  vessels  of  which,  if  they  are  visible,  present  a  yellowish-red 
tint. 

Very  prominent  lesions  are  white  spots  with  red  borders,  especially 
near  the  equator  and  in  the  region  of  the  macula  lutea.  The  spots 
vary  in  size  and  are  often  somewhat  elevated.  They  are  due  to  a 
collection  of  lymph-corpuscles,  and  the  red  border  to  an  extravasation 
of  blood-corpuscles. 

On  the  other  hand,  retinitis  associated  with  leukemia  may  not  pre- 
sent characteristic  appearances,  but  may  consist  simply  of  a  diffuse 
opacity  of  the  retina,  or  appear  in  the  form  of  hemorrhagic  retinitis. 
When  the  yellow  spots  which  have  been  described  develop  in  the 
macula  they  resemble  the  lesions  produced  by  albuminuria.  Indeed, 
albumin  in  the  urine  may  be  present  with  leukemia.  In  any  doul>tful 
case  a  careful  blood  examination  will  reveal  the  true  nature  of  the 
disease. 

Proliferating  Retinitis. — This  affection  is  characterized  by  dense 
masses  of  bluisii-white  or  white  color,  which  are  developed  from  the 
retina  and  stretch  out  into  the  vitreous  humor.  They  often  cover  a 
consideraVjle  portion  of  the  fundus  and  hide  the  jiapilla,  which  may 
with  difficult}'  be  seen  through  the  intervening  spaces.  Sometimes 
the  masses  follow  the  course  of  the  blood-vessels,  which  in  part  may 
lie  beneath  them,  and  in  part  pass  over  them;  those  which  lie  alH)ve 
the  masses  are  occasionally  newly  formed  blooil-vessels.  As  compli- 
cating circumstances  there  may  be  detachment  of  the  retina,  opacity 
of,  and  heuiorrhage  into,  the  vitreous.  Vision  is  usually,  but  not 
always,  greatly  impaired;  sometimes  totally  lost. 

Accoi'ding  lo  Weeks,  the  ('s.-^ential  of  this  (lisea.»<(Ms  the  product itm 
of  membranes  wliicli  extend  from  the  retina  into  the  vitreous  humor, 
and  a  fil)rinous  exudation  or  hemorrhage  must  first  occur  l>efore  these 
meml>ranes  can  i)e  formed.  This  process  and  that  of  vascular  veils  in 
the  vitreous  (see  page  457)  are  similar.  Thus  a  blood  clot  may  organ- 
ize forming  a  sheet  or  mass  of  liltrous  tissue  which  is  vascularized 
by  newly  formed  blood-vessels  derived  from  the  retinal  systen'i.  This  tis- 
sue by  preference  is  situated  ncai  the  disc  ix'cause  there  is  more  meso- 
blastic  tissue  at  this  position  than  elsewhere  in  the  fundus  (Parsons). 


PROLIFERATING    RETINITIS 


481 


Causes. — The  relation  of  recurrent  retinal  hemorrhages  (hemor- 
rhages into  the  vitreous)  to  proliferating  retinitis  has  been  described 
(page  455)  and  its  development  in  diabetes  and  nephritis  has  been 
referred  to.  Sj'philis  is  undoubtedly  a  cause  in  certain  cases  and  its 
evolution  as  part  of  tuberculosis  of  the  retina  has  been  described  (pages 
480  and  482).  To  anemia,  chlorosis,  arteriosclerosis,  menstrual  dis- 
turbances and  the  hemorrhages  which  they  cause  it  has  also  been 
ascribed. 

A  number  of  the  cases  are  due  to  traumatism — penetrating  wounds 
of  the  globe,  concussion  of  the  eyeball  causing  extensive  hemorrhage 
and  retained  intra-ocular  foreign  bodies. 


Fig.   210. — Proiitfiuuug  retinitis  in  an  eail\  sta^e  <iuf  to  tuberculosis.      Note  the  begin- 
ning formation  of  membranes  extending  from  retina  into  vitreous. 


During  warfare,  as  illustrated  in  the  past  war,  various  primary 
intra-ocular  lesions  are  produced  bj^  concussion^  contusion,  or  impact  of 
missiles.  They  result  in  secondary  lesions,  the  most  important  being 
atrophic  chorioretinitis  (spots  of  atrophy,  exposed  scleral  areas  and 
pigment"  distribution,  heaping  and  fringing),  and  proliferating  chorio- 
retinitis. If  the  extravasations  in  the  retina  and  choroid  are  absorbed, 
many  of  the  well-known  appearances  of  pigmented  atrophic  chorio- 
retinitis are  evolved,  though  frequently  its  elaboration  is  most  exten- 
sive, especialh'  in  fan-shaped,  pigmented  granular  areas.  Blood  may 
escape,  and  often  does,  into  the  vitreous  and  may  be  absorbed,  leaving 
all  manner  of  opacities  in  its  place.     Proliferating  chorioretinit.'s  may 

31 


482  DISEASES    OF   THE    RETINA 

follow  aiul  this  chorioretinitis  is  essentially  a  cicatricial  process;  there 
is  organization  of  hemorrhage,  but  this  is  of  less  importance  than  its 
irritating  effect  on  the  connective  tissue  of  the  retinochoroidal  layers, 
inciting  active  proliferation  and  the  formation  of  tracts,  areas  and 
masses  of  fibrous  tissue.  The  whole  process  and  picture  may  differ 
materially  from  the  so-called  proliferating  retinitis  of  recurring  hemor- 
rhages in  the  vitreous  and  retina,  especially  in  young  subjects,  often 
noted  in  civilian  practice.  In  the  type  which  follows  war  injuries  the 
retina  and  choroid  have  been  ruptured,  and  the  cicatricial  process 
results  in  a  pinning  down  of  the  retina  by  opaque,  plastic-looking 
material  rather  than  in  its  detachment,  so  frequent  in  the  ordinary 
variety,  in  which  the  proliferation  arises  from  extravasated  blood,  and 
the  numerous  membranes,  following  the  vessels,  often  partly  trans- 
lucent, protrude  freely  into  the  vitreous. 

Treatment. — This  has  in  part  been  described  (page  456).  Should 
syphilis  be  shown  to  be  an  etiologic  factor,  the  usual  remedies  are  in- 
dicated. In  tuberculous  varieties  of  the  affection  treatment  with  tu- 
berculin may  be  tried  and  has  in  some  instances  achieved  success;  it 
must  be  used  with  caution  and  has  been  followed  in  a  good  many  cases 
by  severe  reaction  and  increase  of  hemorrhages  due  to  violent  local 
reaction.  lodids  and  other  alteratives,  diaphoresis  and  diuresis  are 
worthy  of  trial;  fibrolysin  has  been  referred  to.  The  prognosis  is  most 
unfavorable  if  the  disease  is  extensive;  fresh  hemorrhage  and  fresh  pro- 
liferations are  only  too  common.  The  lesions  of  traumatic  proliferating 
chorioretinitis  are  practically  unaffected  by  treatment.  Detachment 
of  the  retina  is  not  uncommon  and  sometimes  shrinking  of  the  eyeball. 

Tuberculosis  of  the  Retina. — The  relation  of  tuberculosis  to 
various  retinal  affections,  namely  recurrent  retinal  hemorrhages,  retinal 
periphlebitis  and  proliferating  retinitis  (pages  455  and  480)  has  been 
discussed. 

In  some  recent  studies  of  this  subject  Edward  Jackson  and  W.  C. 
Finnoff  conclude  that  retinal  tuberculosis  begins  by  the  formation  of 
white  infiltrations  in  front  of  retinal  vessels,  generally  the  veins.  At  a 
later  period  perivasculitis  and  hemorrhages  are  manifest;  the  hemor- 
rhages may  disappear  and  may  be  completely  absorbed  if  they  are 
small  and  confined  to  the  retina,  or  they  may  he  large,  nuissive  and 
burst  into  the  vitreous.  In  these  circumstances  the  well-known  ap- 
pearances of  proliferating  retinitis  (page  480)  develop.  White  spots, 
something  like  those  seen  in  renal  retinitis  may  arise  ami  add  to  the 
<iej)reciati()n  of  vision.  In  a  case  studied  recently  by  tlu^  author  the 
typical  white  infill lations,  three  in  number,  appeared  along  the  superior 
temporal  vein,  which  was  irregularly  contracted.  A  sharp  exacerba- 
tion followed  a  tuberculin  injection,  when  numerous  fresh  white  spots 
appeared  in  front  of  liiis  vein  and  on  some  of  its  connecting  branches, 
with  minor  ai'eas  of  retinal  hemorriiage;  ulliiiiatcly  tiiey  sultsideil. 
The  course  of  the  disease  may  be  protracted. 

Treatment.  In  ilic  absence  of  pyrexia  and  extensive  tuberculosis 
elsewlicrc   in   I  lie  IkmK,  .I.ackson  and  I'MnnolT  rei-oniniend  t  uluTculin, 


RETINITIS    STRIATA 


483 


which,  however,  must  be  very  cautiously  given.     General  supporting 
measures  are  indicated. 

Retinitis  Circinata. — This  name  was  applied  by  Fuchs  to  an 
affection  characterized  by  a  concentric  aggregation  of  slightly  raised 
white  spots  and  lines  around  the  macula.  Sometimes  the  white  spots 
surround  the  macula  after  the  manner  of  a  wreath;  sometimes  the 
arrangement  is  more  like  that  of  an  ellipse,  one  end  of  which  may  touch 
the  edge  of  the  optic  disk,  while  the  other  extends  beyond  the  macular 
region  (Lawf  ord) .  Fuchs  regards  the  white  patches  as  fibrinous  exuda- 
tions which  have  taken  place  into  the  deeper  layers  of  the  retina,  while 
de  Wecker  denied  the  special  character  of  the  disease,  which  he  attrib- 
uted to  fatty  degeneration,  the  result  of  hemorrhages.     Indeed,  Am- 


FiG.  211.- — Circinate  retinitis  (from  a  patient  in  the  Jefferson  Hospital). 

man  has  shown  that  the  white  spots  are  due  to  fatty  cells  clustered 
where  hemorrhages  have  been.  Hemorrhages  may  accompany  the 
affection,  and  in  one  case  (Fridenberg)  there  was  a  development  of 
new-formed  blood-vessels  in  the  retina.  The  lesions  have  also  been 
attributed  to  disease  of  the  smallest  macular  vessels,  especially  the 
arteries  (Oeller),  and  also  to  the  results  of  a  long-standing  edema,  the 
size  of  the  circle  varying  according  to  the  extent  of  the  previous  affec- 
tion (Gunn).  Sometimes  the  disease  is  essentially  chronic  and  the 
appearance  remains  unchanged  for  years;  sometimes  it  is  slowly  but 
surely  progressive,  and  rarely  the  ring  of  exudate  may  partly  or  entirely 
disappear.  Such  disappearance  within  one  year  has  been  noted  by 
N.  Bishop  Harman. 

Retinitis  Striata. — Occasionally  light  or  yellowish-white  stripes 
extending  from  the  periphery  toward  the  disk,  and  sometimes  bordered 
by  lines  of  pigment  lying  beneath  the  retinal  vessels,  are  apparent  to 


484 


DISEASES    OF    THE    RETINA 


the  ophthalinost'opo.  To  tliis  appearance  the  name  retinitis  striata 
has  been  given,  and  while  the  origin  of  the  affection  is  not  positively 
known,  Hoklen  contends  that  the  stripes  are  the  result  of  the  metamor- 
phosis of  retinal  hemorrhages,  and  in  this  respect  are  analogous  to 
angioid  streaks.  On  the  other  hand,  it  has  l)een  contended  by  L. 
Caspar  that  these  retinal  striations  represent  the  final  stages  of  spon- 
taneously cured  detachments  of  the  retina.  The  author  has  published 
the  case  histories  of  two  patients  which  appear  to  confirm  this  view 
of  the  origin  of  retinitis  striata. 

Pigmentary  Degeneration  of  the  Retina  {Retiniti.'i  Pigmentosa). 
Although  this  affection  is  usually  entitled  retinitis  pigmentosa,  the 
phenomena  of  inflammation  are  absent,  and  it  consists  of  a  degenera- 
tion of  the  retina,  associated  with  great  contraction  of  the  blood-vessels 
and  the  accumulation  and  deposition  of  pigment  from  the  pigment 
epithelium  of  well-nigh  characteristic  form  in  the  substance  of  the 
retina.     Roth  eyes  are  always  affected. 

Symptoms. — The  ophthalmoscopic  appearances  of  a  typical  case 
are  as  follows: 

(a)  Pigmentation. — The  pigment  masses  frequently  assume  an  ap- 
pearance resembling  bone-corpuscles,  and  by  the  union  of  their  proc- 
esses suggest  the  Haversian  canals.  The  resemblance  of  the  pigment 
to  bone-corpuscles  is  not  always  evident;  the  pigment  deposits  may 
be  round  and  irregular  and  sinuilate  the  pigment  spots  of  choroiilitis. 
but  unlike  them  they  are  situated  in  front  of  the  blood-vessels  ;ind 
are  in  the  inner  layers  of  the  retina.  Bv  pri-ference.  the  pj^niexitajy 
deoiisits  are  more  marked  on  the  temporal  sid(\  Tlipv  botrjn  in  i\\e 
'-trround. 


pei'ip^^fMY^— 'It  Thr  py^'-yiound.  ~alt  hough  m>t  usually.^ui  llic  ('xtj_('nie 
periphery,  often  lying  alotig  the"  course  of  the  main  vessels,  wbicli  niav 
b<liii  p]ace5"cncriisrecri)y  them,  aim  ^nuliially  aj)jii()ach  theiniplTla.  the 
macular  region  remaining  for  a  long  time  unaffected.  A  zone  mid-way 
between  t  he  center  and  far  periphery  is  tjie  favorjk'X^^^t  of  pigmeittrTTtftn. 
^~^b)  ~" W'din.sedTcd ' '  Fundus.— \  perfect  picture  of  the  appearani-e 
already  descrilx'd  in  connection  with  su])erficial  choroiditis  is  visil)le  on 
account  of  the  absorption  and  decolorization  of  the  retinal  pignuMit 
epithelium  and  the  exposure  of  the  larger  vessels  of  th(>  choroid.  The 
overlying  retina  is  distinctly  gray. 

(c)  Contraction  of  the  \'essels. — This  is  present  in  l)oth  systcMus. 
The  vessels  nuiy  be  as  thin  as  threads.  Often  tlieir  walls  exhil)it 
patches  of  opacity,  and  they  are  accompanied  by  fine  white  lines  ami 
covered  here  and  there  by  pigment  deposits.  Not  onl\'  :\vv  they 
greatly  contracted,  but  they  are  apparently  diminished  in  nuinl>er. 

((I)  The  Changed  \erre-head.  The  coloi-  of  tlie  papilla,  acciirding 
to  the  stage  of  the  disease,  is  of  a  yellowish-gray,  yellowisli-red.  or  waxy 
tint.  It  finally  becomes  dull  wliite  and  atrophic,  l-'xcept  a  slight 
veiling,  its  edges  are  plainly  markrd. 

(c)  Opacities  of  the  .Malta.  Cataract  at  the  posterior  pole  is  fre- 
(juentlN'  present,  and  in  the  later  stages  post eiior  cortical  cataract, 
(see  I''ig.  200).      ()p;iciti('s  in  the  \itrcous  arc  unc<uiinioii. 


PIGMENTARY    DEGENERA  TIOX    OF    THE    RETINA 


485 


(/)  Nystagmus. — Quite  frequently  a  quick  lateral  oscillation  of  the 
ej'eballs,  or  m'stagmus,  is  present,  especially  in  congenital  cases. 

The  subjective  symptoms  are: 

(a)  Depreciation  of  Central  Visio7i. — Visual  acuteness  maj'  be  but 
slightly  affected  in  the  earlier  stages,  although  usualh^  the  perception 
of  green  and  red  is  below  the  normal.  Indeed,  reasonabty  good  cen- 
tral vision  may  remain  even  when  the  disease  is  very  wide-spread,  but 
it  finally  sinks  with  the  progress  of  the  affection  and,  ultimately, 
blindness  results,  although  this  usually  does  not  occur  until  the  expira- 
tion of  many  years. 

{b)  Contraction  of  the  Field  of  Vision. — In  the  earty  stages  of  pig- 
mentary degeneration  of  the  retina  the  peripheral  field  of  vision  maj^ 
be  nearly  normal  in  extent,  if  the  illumination  is  good,  although  much 
contracted  if  the  illumination  is  reduced.     Later,  the  field  contracts 


Fig.   212. — Ring  .scotomas  in  pigmentary  degeneration  of  the  retina. 


concentrically,  according  to  the  amount  of  degeneration,  and  the 
contraction  may  be  so  excessive  that  only  a  very  small  area  of  the 
field  remains.  In  rare  instances,  even  with  extreme  narrowing  of 
the  visual  field,  there  is  still  moderately  good  central  vision,  and  the 
patient  may  read  by  fixing  a  single  word  at  a  time.  Finally,  the  con- 
traction goes  on  to  complete  blindness.  As  the  extreme  periphery  of 
the  retina  is  often  free  from  pigmentation  in  the  earliest  stages  of 
the  disease,  when  the  equatorial  region  is  already  involved,  the  periph- 
ery of  the  visual  field  may  be  intact,  but  between  it  and  the  preserved 
central  field  there  is  a  blind  zone;  that  is,  an  annular  or  ri7ig  scotoma. 
Indeed,  the  earliest  manifestation  of  primarj-  degeneration  is  this  ring 
scotoma  (M.  L.  Hepburn).  At  first  it  is  incomplete  and  represents  the 
loss  of  function  in  the  intermediary  zone  of  the  retina.  Later  other 
portions  of  the  retina  degenerate  in  regular  order,  the  fixation  point 
being  the  last  to  disappear. 

(c)  Night-blindness. — L'sually  this  is  the  first  symptom  which  calls 
attention  to  the  case.  The  patient  is  uncertain  in  his  movements  and 
stumbles  as  soon  as  twilight  begins,  becoming  quite  helpless  in  the 


486  DISEASES    OF   THE    RETINA 

dark.  Pronounced  ni!?ht-l)lindness  is  not  always  present,  and  in  rare 
instances  diminished  light  is  a  relief  to  the  patient.  Such  a  condition 
is  due  to  retinal  hyperesthesia. 

Atypical  Varieties. — The  pip;ment  may  be  massed  in  the  macular 
region;  the  central  vision  is  much  affected,  and  a  scotoma  appears 
around  the  point  of  fixation.  In  other  instances  the  pigment  is 
scattered  all  over  the  fundus  in  irregular  masses,  and  is  associated 
with  clear,  shining  spots  lying  })eneath  the  retinal  vessels. 

Cases  occur  presenting  the  usual  subjective  symptoms,  but  without 
the  accumulation  of  pigment — really  forms  of  sclerosis  of  the  retina 
without  the  formation  of  pigment,  and  constitute  the  so-called  pigment 
degeneration  without  pigment.  Even  in  the  very  beginning  of  jiigmen- 
tary  degeneration  of  the  retina  there  maj'  be  no  pigmentation  visible 
in  the  ophthalmoscope.  But  in  the  cases  referred  to  migration  of  pig- 
ment into  the  retinal  substances  is  not  observable  for  many  years,  in- 
deed it  may  not  appear  at  all,  although  waxy  disk  degeneration  and 
contracted  vessels  are  evident.  Therefore  pigmentation  is  not  neces- 
sarily an  essential  condition  of  the  disease.  A  diffuse  opacity  of  the 
retina  has  Vjcen  observed  in  some  of  these  cases  (Leber). 

Retinitis  Punctata  Albescens. — This  type  of  retinal  affection 
was  originally  described  by  Mooren,  and,  according  to  him,  is  character- 
ized by  a  great  number  of  striae  or  spots  scattered  over  the  fundus, 
resembling  in  color  the  reflex  of  the  sclera.  The  retinal  vessels  are 
not  covered  by  the  spots.  The  papilla  is  decidedly  gray.  A  relative 
or  a  positive  scotoma  may  be  present.  To  a  similar  retinal  disease  the 
name  central  and  punctate  retinitis  has  been  given  (Hirschberg).  Fuchs 
has  called  attention  to  the  similarity  of  this  disease  to  retinitis  pig- 
mentosa, inasmuch  as  it  is  either  congenital  or  starts  in  infancy,  atTects 
several  members  of  the  same  family,  and  may  occur  in  the  children  of 
blood  relations.  Also,  there  may  be  night-blindness  and  contraction 
of  the  visual  field.  As  John  Griffith  has  pointed  out,  it  should  be 
regarded  as  a  primary  degeneration  of  the  retina  and  choroid  allied 
to  pigmentary  degeneration  of  the  retina,  and  should  not  be  classified 
as  an  inflammatory  disease.  Leber  classifies  the  condition  as  a  form 
of  non-pigmented  tapeto-retinal  degeneration  and  believed  that  the 
white  spots  represented  partly  cakifietl  colloitl  excrescences  of  the 
lamina  vitria  (druses).  Nettleship,  however,  was  not  willing  \o  ailmit 
this  origin  of  the  lesions. 

Another  type  of  chronic  retinal  degeneration  is  that  to  which  Fuchs 
gives  the  name  alropliid  gyrata  choroixlva'  ct  rctiiui,  also  stu'u  in  th(>  chil- 
dren of  consanguineous  marriag(>s  and  associated  witli  night-blinchiess. 
There  is  extensive  atrophj'  of  pigment  epithchum  of  the  dioroid,  which 
may  be  perij)lierally  situated  and  appear  as  a  wliite  zone  with  an  irregu- 
lar border,  or  nearly  the  whole  fundus,  except  an  area  around  the 
nuicula,  may  be  involved,  (lencrally  the  pigment nt ion  prcs(>nt  is 
identical  with  tiiat  of  retinitis  pignicMitosa. 

Cases  of  pigmentary  degeneration  of  tlie  retina  with  l(>sions  espe- 
cially  lo('at<'(l  in  tli(>  niMcul.nr  icgion  are,  according  to  Nettelship,  not 


PIGMENTARY    DEGENERATION    OF    THE    RETINA  487 

very  uncommon,  ehe  morbid  process  being  either  congenital  or  having 
begun  early  in  life.  The  area  at  the  posterior  pole  has  a  granular  appear- 
ance and  the  pigmentation  is  in  the  form  of  dots  and  not  of  the  "bone 
corpuscle  type."  The  patch  of  macular  change  may  have  an  irregular 
but  defined  outline,  or  blend  with  the  surrounding  retina  which  appar- 
ently is  not  diseased;  or  beyond  there  may  be  a  zone  of  typical  pig- 
mented retina.  For  lesions  of  this  and  similar  character,  attributed  by 
him  to  abiotrophy  of  the  retinal  neuro-epithelium,  Colhns  suggests 
the  designation  "pigjyientary  macular  retinal  degeneration,^^  or  "retinitis 
pigmen  tosa  of  the  macula. ' '  (For  other  types  of  macular  retinal  degenera- 
tion, see  pages  514,  515.) 

Complications. — Retinitis  pigmentosa  may  be  complicated  with 
chronic  glaucoma,  the  retinal  affection  probably  antedating  the  glau- 
coma (Bellarminoff,  Mandelstamm).  In  one  f amity  several  members 
of  which  have  typical  pigmentary  degeneration  of  the  retina  the  author 
has  observed  two  with  glaucoma,  in  one  instance  assuming  a  subacute 
type  successfully  controlled  by  operation.  Holloway  has  described  pig- 
mentary degeneration  of  the  retina  in  association  with  albuminuric 
neuroretinitis.  In  addition  to  cataract,  nystagmus,  strabismus,  deaf- 
ness (33  per  cent.  [Nettleship])  harelip,  supernumerary  toes  and  fingers 
and  other  congenital  anomalies  occur. 

Causes. — The  disease  is  markedly  hereditary.  Simeon  Snell  has 
reported  the  history  of  this  affection  in  five  generations,  28  of  the  67 
descendants  being  affected.  Consanguinity  of  the  parents  of  the  sub- 
jects of  this  disease  has  been  found  in  a  certain  number  of  cases;  indeed, 
the  disease  has  been  attributed  to  this  cause  alone.  Nettleship's  results 
are  as  follows:  Heredit}'  without  consanguinity  in  23.5  per  cent.,  con- 
sanguinity without  heredity  in  23  per  cent.,  and  heredit}^  combined 
with  consanguinity  in  3  to  4  per  cent.  Hereditary  syphilis  has  been 
suggested  as  a  possible  cause  of  retinitis  pigmentosa,  but  this  etiology 
has  not  been  proved.  The  affection  is  found  among  deaf  mutes  (4  per 
cent.  [Nettleship]),  idiots,  and  epileptics,  and  in  this  sense  is  connected 
with  morbid  states  of  the  nervous  system.  Very  often  no  cause  can 
be  assigned.  The  disease  is  either  congenital  or  usually  begins  in 
childhood;  it  may,  however,  arise  at  any  age  of  life.  According  to 
W.  T.  Shoemaker,  it  is  always  congenital  in  origin,  no  matter  how  late 
its  manifestations  are  evident.  According  to  Nettleship  acute  exanthe- 
mata, tuberculosis,  excessive  loss  of  blood  and  syphilis  may  determine 
the  onset  of  the  disease  if  in  the  choroid  and  retina  a  predisposition 
exists. 

Pathology  and  Pathologic  Anatomy. — A  degenerative  process  begins 
early  in  the  outer  layers  of  the  retina,  which  becomes  adherent  to  the 
choroid.  The  rods  and  cones  disappear,  the  blood-vessels,  choroidal 
and  retinal,  are  sclerosed,  those  of  the  choriocapillaris  being  the  first 
affected,  and  their  lumens  contracted.  There  is  a  marked  infiltration 
of  pigment  cells,  the  pigmentation  being  a  secondary  change  produced 
because  the  blood  supply  is  checked.  Later  the  degenerative  process 
reaches  the  la3'er  of  ganglion  cells  and  the  nerve-fibers.     The  optic 


488 


DISEASES    OF    THE    RETINA 


nerve  atrophies  and  may  contain  h>  aline  masses  similar  to  those  in  the 
lamina  vitrea  of  the  choroid.  Waficnmann  believes  that  the  primary 
lesion  is  a  sclerosis  of  the  vessels  of  the  choroid.  Clonin  and  Xettleship 
attribute  the  primary  degeneration  to  deficient  blood-supply  owing  to 
obstruction  to  the  blood-current  in  the  choriocapillaris.  The  })egin- 
ning  of  the  disease  has  also  been  jjlacedin  the  pigment  epithelium.  The 
affection  is  always  l)ilateral.  The  statements  thus  far  recorded  are 
in  brief  summary  the  ones  usually  made  with  reference  to  the  pathology 
and  pathologic  anatomy  of  retintis  pigmentosa.  Quite  recently  E. 
Treacher  Collins  has  advocated  an  entirelv  new  theorv.     The  chief 


Fig.   21.3. — Pijimentary    detieneration    of    the    retina;   inaiki-d    exposiiro    of    vessels    of 
choroid  (from  a  i)atic'ut  in  the  I'liiversity  Hospitals 

argument ,  <|u<)ling  ( 'oUins,  against  vascular  sclerosis  being  the  primary 
cause  of  pigmentary  degeneration  of  the  retina  is  that  typical  ca.ses 
have  been  investigated  in  which  no  changes  in  the  choroidal  blood 
vessels  were  found  in  the  affected  ey(>s  microscopically  examined. 
He  suggests  that  the  primary  change  is  ahiolrophy,  that  is,  degenera- 
tion of  ti.ssues  due  to  defective  vitality,  of  the  retinal  neuroepithelium 
wliicli,  he  believes,  explains  all  the  symptoms  of  the  disease.' 

Diagnosis,  i^'tinitis  pigmentosa  may  b(>  distinguished  from  dis- 
seminated choi-oidil  is  b\-  the  dirrerenfc  in  tlie  pignieiilat  ion  of  the  two 
diseases. 

Its  differential  diagnosis  from  ceit.-iiii  ly|)es  of  pigmented  retino- 
<;horoiditis  seen  in  ac(iuired  sy|)hilis  is  dillicnlt,  especially  where  the 
latt<*r  manifest  tliemselves  in  a  form  of  atrophy  of  the  retina  aiui  a 
•TrunsuctionH  iif  till- ( )|(htlialiiii>h>nic  S<i(ict\  1)1"  the  l",  I\.  \ul.  \\\i\.  i'.M'.i,  p.  1(>.'). 


PIGMENTARY    DEGENERATION    OF    THE    RETINA  489 

gathering  of  pigment  spots,  beneath  which  tlie  exposed  choroidal  vessels 
are  visible.  In  retinochoroidits,  however,  the  pigment  spots  do  not 
have  the  characteristic  form:  they  are  much  scattered,  and  do  not  follow 
or  cover  the  blood-vessels;  besides,  vitreous  opacities,  which  are  com- 
paratively rare  in  pigmentary  degeneration  of  the  retina,  are  usually 
present.  The  visual  field  should  lend  aid  in  diagnosis,  as  in  choroidal 
disease  the  characteristic  feature  is  the  patchy  nature  of  the  scotomas 
(M.  L.  Hepburn). 

A  patient  with  night-blindness,  or  seen  stumbling  about  during  the 
twilight,  should  be  subjected  to  a  careful  examination  of  the  periphery 
of  the  eye-ground,  if  necessary,  after  dilatation  of  the  pupil,  because 
occasionally  the  pigment  is  confined  to  this  region  and  might  otherwise 
be  overlooked.  Sclerosis  of  the  retina  without  pigmentation  must  be 
kept  in  mind  and  the  clinical  and  family  history  carefully  studied,  as 
well  as  the  visual  field. 

Course  and  Prognosis. — Pigmentary  degeneration  of  the  retina 
almost  always  progresses  steadily  onward  with  ever-increasing  con- 
traction of  the  field  of  vision,  until  finally,  usually  by  middle  life, 
sight  has  been  obliterated,  with,  perhaps,  the  exception  of  a  slight 
eccentric  preservation  of  the  field.  According  to  Nettleship,  the  age 
at  which  blindness  becomes  complete  is  variable,  and,  with  rare  excep- 
tions, occurs  only  after  the  thirtieth  to  the  thirty-fifth  year  of  life; 
more  usually  after  sixty  years.  The  prognosis  is,  hence,  nearly  always 
unfavorable  in  all  circumstances  and  in  spite  of  all  known  endeavors 
to  modify  the  course  of  the  disease.  Occasionally  congenital  cases 
remain  stationary.  Sometimes  when  the  pigment  accumulation  has  ad- 
vanced far  over  the  retina,  but  the  macula  is  still  free,  the  disease 
remains  stationary  for  long  periods  of  time,  and  good  vision  within  the 
narrow  field  continues  . 

Treatment. — Strychnin  in  full  doses,  especially  by  the  hypodermic 
method  is  frequently  employed  and  recently  thyroid  extract  has  been 
advocated  (Jones).  If  there  is  any  suspicion  of  syphilitic  taint,  the 
usual  remedies  are  indicated.  Galvanism  has  been  tried,  and  under  its 
influence,  it  is  stated,  the  progressive  contraction  of  the  field  of  vision 
has  been  stayed,  although  no  improvement  in  the  acuteness  of  central 
sight  was  obtained.  It  certainly  should  be  given  a  trial  in  every  case 
It  is  always  important,  considering  the  slow  advance  of  many  of  the 
cases  of  retinitis  pigmentosa  to  correct  refractive  error  carefully;  there 
may  be  present  considerable  degrees  of  astigmatism  and  suitable  glasses 
not  infrequently  are  of  advantage  in  improving  central  vision. 
Iridectomy  has  been  tried  and  paracentesis  of  the  anterior  chamber. 
An  encouraging  result  in  increasing  the  size  of  the  visual  field  by 
corneoscleral  trephining  has  been  obtained;  in  one  case  night-blindness 
disappeared  and  remained  absent  for  some  months  (Mayou) .  Although 
the  posterior  cortical  cataract  of  this  disease  rarely  reaches  maturity, 
the  lens  should  be  extracted  as  vision  may  be  thus  materially  improved 
(Doyne,  Knapp).  The  author  has  had  a  few  excellent  results  by 
adopting  this  procedure. 


490  DISEASES    OF   THE    KETIXA 

Sometimes  a  peculiar  pigmentation  of  the  retina  is  encountered  which 
has  been  mistaken  for  a  type  of  retinitis  pip;inentosa,with  which  disease, 
however,  it  has  no  alHance.  The  pigment  changes  occupy  a  sector  of 
the  eye-ground,  and  consist  of  collections  of  black  or  chocolate-brown 
spots,  with  a  strong  tendency  to  group  formation.  The  spots  may  be 
round,  oval,  and  often  suggest  diminutive  bunches  of  grapes.  This 
appearance  was  figured  by  Jaeger,  has  been  described  by  Juler,  Stejihon- 
son,  and  others,  and,  quite  recently,  elaborately  by  Hoeg.  It  is  doubt- 
less a  congenital  condition;  the  function  of  the  eye  is  undisturbed. 
The  author  has  seen  a  number  of  cases  of  this  character  and  no  increase 
in  the  lesions  has  been  noted,  although  several  of  the  patients  have 
been  under  observation  for  years. 

Detachment  of  the  Retina  (Ablatio  Retince;  Amotio  Retinoe). — 
Separation  of  the  retina  from  the  underlying  choroid  (so-called  spon- 
taneous detachment)  is  due  to  an  accumulation  of  a  serous  fluid  be- 
tween these  membranes  (serous  detachment  of  the  retina). 

Sjonptoms. — The  student  will  observe,  as  he  examines  the  various 
portions  of  the  fundus  with  the  ophthalmoscope  (direct  method),  an 
alteration  of  refraction  at  the  area  of  separation,  the  surface  of  the 
elevation  thus  produced  being  out  of  focus  as  compared  with  the  rest 
of  the  eye-ground.  Thus,  if  the  general  fundus  is  hyperopic,  the  de 
tached  portion  will  be  more  hyperopic,  and  require  a  stronger  convex 
glass  for  the  study  of  its  surface;  if  it  is  highly  myopic,  a  weaker  cotf 
cave  glass,  or,  it  may  be,  a  convex  lens. 

The  normal  color  of  the  fundus  is  lost  as  the  detached  retina  is 
approached,  which  appears  as  a  gray  or  bluish-gray  membrane  stretch 
ing  forward  into  the  vitreous,  containing  folds  which  give  rise  to 
sheen.  The  intervening  furrows  present  a  greenish-gray  reflex,  and 
the  whole  oscillates  with  the  movements  of  the  eye  if  the  underlying 
substance  is  fluid;  if  it  is  a  solid,  neither  folds  nor  tremulousness  are 
present.  Rents  in  the  detached  retina,  through  which  the  choroid  is 
visible,  are  often  demonstrable. 

The  retinal  vessels  rise  over  the  separated  portion,  first  lose  the 
light-streak,  and  finally  appear  as  dark,  tortuous  cords.  They 
apparently  are  of  smaller  size  than  normal,  anil  if  followed  back- 
ward they  pass  out  of  focus  at  the  edge  of  the  detachment,  which  is 
usually  sharply  marked  from  the  normal  fundus;  indeed,  there  may 
be  a  yellowish  border  and  occasionally  accuimilatcil  ]Mgment.  The 
amount  of  discoloration  of  tlu;  detached  area  depeiuls  upon  whether 
the  case  is  recent  or  not,  anil  upon  the  character  of  the  underlying 
substance.  In  the  earlier  stages  transparency  is  not  lost,  and  the 
gray  color,  previously  descriheil,  may  not  be  present. 

■^I'lio  detachnieiil ,  eitiier  jxirtidl  or  (•(niiphlc,  may  occupy  any  portion 
of  the  fundus,  hul  coinmoiily  is  found  below,  precedeil,  it  may  be,  l>y  a 
separation  of  the  retina  in  the  upper  part  of  the  eye-ground.  These 
superior  detachments  may  sag  downward  and  bulge  forward  into  the 
vitreous  like  a  diminulive  l)alloon.  Occasionally  a  superior  detach- 
riienl  is  transferred  to  ;in  inferioi  position.     The  suhretiniil  Ihiid  seeps 


X 


DETACHMENT    OF    THE    RETINA  491 

to  the  lower  area  and  the  originally  separated  portion  of  the  retina  is 
reattached.  Sometimes  the  detachments  are  quite  small,  like  a  series 
of  furrows,  and  at  other  times  an  almost  circular  circumscribed  sep- 
aration occurs.  Finally,  the  subjective  signs  of  detachment  may  be 
present  without  discoverable  elevation  of  the  retina,  but  over  the  area 
(which  subsequent^  separates)  there  is  complete  loss  of  the  light  reflex 
from  the  retinal  vessels  (Loring).  In  these  circumstances  the  visual 
field  should  be  mapped  under  reduced  illumination.  At  first,  owing 
to  the  small  quantity  of  subretinal  fluid,  the  detachment  may  be  flat; 
occasionally  it  remains  so,  but  usually  it  increases  in  extent  and 
elevation. 

Unless  the  macular  region  is  directly  involved,  vision  is  not  obliter- 
ated, but  there  is  always  interference  with  sight.  This  may  develop 
suddenl}'.  The  field  of  vision  is  lost  in  an  area  corresponding  to  the 
detached  retina,  and' the  completely  darkened  portion  is  usuallj^  bor- 
dered by  a  zone  of  imperfect  vision  corresponding  to  an  area  of  retina 
not  3^et  separated,  but  elevated  above  its  normal  plane.  If  the  retina 
is  detached  below,  the  upper  portion  of  the  visual  field  is  obliterated; 
if  above,  the  lower  portion,  and  so  on  (Fig.  215).  A  retinal  detach- 
ment just  beginning  may  not  be  detected  by  a  visual-field  examina- 
tion with  a  white  test-object,  but  may  be  represented  by  a  relative 
scotoma  if  the  test-object  is  blue. 

The  patients  are  conscious  of  distortion  of  objects  (metamor- 
phopsia) ;  of  floating  spots  before  the  eyes,  due  to  the  frequent  presence 
of  vitreous  opacities;  of  an  appearance  like  a  cloud,  due  to  the  scotoma 
produced  by  the  separated  area;  and  of  phosphenes,  althougli  the  last 
cannot  be  elicited  by  pressure  on  the  eyeball  over  the  separated  area. 
Should  a  patient  with  high  myopia  describe  "attacks"  of  flashes  of 
light,  showers  of  sparks,  or  other  types  of  photopsies,  such  symptoms 
are  dangerously  significant  of  impending  retinal  detachment.  Exte- 
riorly the  eye  ordinarily  presents  no  abnormalities.  Sometimes 
the  anterior  chamber  is  deep;  the  tension  maj'  be  diminished.  In 
late  stages  of  retinal  detachment  the  vitreous  becomes  exceedingly 
cloudy  owing  to  increasing  the  vitreous  opacities;  cataract  frequently 
forms  and  becomes  complete.  Iritis  and  iridocyclitis  may  develop 
and  although  the  tension  is  usually  lower  than  normal  in  detach- 
ment of  the  retina,  if  seclusion  of  the  pupil  takes  place  as  the  result  of 
iridocyclitis  it  may  be  elevated. 

Causes. — The  causes  of  ordinary  retinal  separation  are :  High  (malig- 
nant) myopia;  traumatisms  and  effusions  of  blood,  preceded  usually  by 
hemorrhages  into  the  vitreous  or  retina.  More  men  than  women  ac- 
quire simple  detachment  of  the  retina;  myopic  refraction  most  fre- 
quently is  present,  and  the  separation  is  more  apt  to  occur  in  an  eye  in 
which  the  visual  disturbance  has  rapidly  developed.  The  condition 
often  becomes  apparent  suddenly,  especially  after  phj^sical  exertion; 
occasionally  it  develops  gradually. 

Retinal  detachment  is  also  caused  by  intra-ocular  tumors  (sarcoma 
of  the  choroid)  or  subretinal  parasites  (cysticercus) ,  tumors  and  ab- 


492 


DISEASES    OF   THE    RETINA 


scesses  in  tlic  orbit,  and  diseased  conditions  of  the  eye,  as  retinitis, 
cyclitis,  iridocyclitis,  etc.  In  iridocyclitis  the  detachment  is  often 
found  only  after  removal  of  the  shrunken  globe,  and  is  caused  by  con- 
traction during  organization  of  strands  of  connective  tissue  attached 
to  the  retina.  Separation  of  the  retina  may  be  congenital,  due  to  syph- 
ilis, and  it  has  been  observed  in  several  members  of  the  same  family 
(hereditnry  detachment  of  retina — Pagenstecher).  Subretinal  hemor- 
rhage— the  blood  coming  either  from  the  retina  or  choroiti — may 
produce  the  so-called  hemorrhagic  detachment  of  the  retina,  for  example, 
in  the  subjects  for  arteriosclerosis,  but  also  in  anemia  and  chlorosis. 
In   traumatic  detachment  of   the   retina   the  eve  is   usuallv,    but    not 


Fni.   :-'ll.  —  Detachment  of  lower  half  of  retina,  which  has  floated  forward. 
iil>per  half  of  fundus  dimly  seen. 


Dir-k  and 


necessarily,  myojjic;  the  separation  may  immediately  follow  the 
injury  or  l)e  delayed  for  weeks  or  even  months.  The  cicatrix  which 
follows  a  penetrating  wound  of  the  sclera  fastcMiing  as  it  does  the 
retina  to  the  choroid  and  sclera  liy  later  contraction  may  detacii 
the  let  ilia. 

Mechanism. — Leber  and  Noidenson  hold  that  tli(>  first  process  is  a 
fibrillar  change  in  the  viticous,  which  shrinks  and  oi-casions  traction 
(retraction  theory).  This  ruptures  the  retina,  and  the  lluid  from  the 
vitreous  cavity  passes  beneath  it  through  the  opening.  The  primary 
cause  of  the  pathologic  alteiation  in  the  vitr(M)us  is  believed  to  be 
disease  of  the  choroid  and  ciliary  body.  (IreetT,  I'llschnig.  and  others, 
however,  doubt  if  retinal  detachment  is  caused  by  shrinking  of  the 
vitreous;  detachment  of  the  viticous  they  icgard  as  ;in  artefact  ilue 
to  the  action  of  lluids  used  in  haitlciiing  tlu'  e\-eball.  liaehlmann 
evplainei!  the  (Ictachnienl  1)\-  a  (lllhision  theory,  the  conditions  l>eing 
analogiMis  lo  t  laiisudat ions  in  other  parts  of  the  Ixxly.  In  some 
instances    rrliiial    dct  ;icliiiiciit    must    be   e\|)laine(l    by    tiii"    pi'eseiice   of 


DETACHMENT    OF    THE    RETINA 


493 


exudation  or  hemorrhagic  extravasation,  and  in  axial  mj'opia  of  high 
degree  the  "mechanical  theory"  is  applicable — the  separation  of  the 
retina  being  due  to  elongation  of  the  eyeball,  fluidity  of  the  vitreous, 
and  hyperemia  of  the  choroid.  In  general  terms  these  factors  may  be 
active:  distension  of  the  eyeball  as  in  myopia,  subretinal  exudation 
from  choroidal  effusion  and  traction  on  the  retina  from  within.  De- 
tachment of  the  retina  in  renal  retinitis  has  been  described. 

Diagnosis. — No  difficulty  arises  in  detecting  a  large  detachment  of 
the  retina  bj^  attending  to  the  symptoms  already  detailed.  An  exten- 
sive or  complete  detachment  which  floats  far  forward  mav  be  exam- 


FiG.   215. — Various  types  of  fields  of  vision  in  detachment  of  the  retina. 


ined  by  oblique  illumination.  If  the  vitreous  is  full  of  opacities,  a 
study  of  the  field  of  vision  is  useful.  If  the  substance  underlying 
the  detached  portion  is  fluid,  there  are  usually  diminished  tension  of 
the  eyeball  and  the  appearance  of  furrows  in  the  separated  tissue,  which 
trembles  with  the  movements  of  the  eye,  s\'mptoms  which  are  absent 
if  a  solid  growth  has  caused  the  separation.  Important  diagnostic 
signs  are  the  loss  of  the  light-reflex  of  the  vessels,  and  their  dark  color 
over  the  area  of  separation.  They  can  be  seen  to  regain  the  light- 
reflex  in  passing  over  the  normal  retina.  It  is  important  to  submit  all 
eyes  with  detachment  of  the  retina  to  the  transillumination  test  (see 
page  391). 

Prognosis.^ — This  is  not   very  favorable,   and  many  of  the  sug- 
gested means  of  treatment  have  proved  unsatisfactory.     Even  though 


494 


DISEASES    OF   THE    RETINA 


they  should  be  followed  by  reattachment  and  the  function  of  the  retina 
should  be  restored  the  good  effect  is  only  too  frequently  not  a  la.^tinp; 
one  because  vitreous  disease  continues.  However,  good  and  permanent 
results  have  been  secured  and  suitable  measures  should  be  given  full 
trial.  Duane,  quoting  Leber,  says  a  cure  in  the  sense  of  a  reattach- 
ment takes  place  in  about  8.5  per  cent,  of  the  cases,  but  the  restora- 
tion of  even  moderately  useful  vision  only  in  from  3-0  per  cent,  of  the 
cases.  In  a  few  instances  spontaneous  reattachment  of  the  retina  takes 
place.  In  the  reattached  area,  spots  of  choroiditis  are  often  visible  and 
variously  disposed  striae,  white  or  fringed  with  pigment  (see  page  508). 

Treatment. — This  should  include  rest  in  the  prone  position,  a  pres- 
sure bandage,  preferably  elastic,  and  pilocarpin  sweats,  the  pujiil  of 
the  affected  eye  being  dilated  with  atropin,  and  lymphagogue  activity 
stimulated  by  the  use  of  a  5  per  cent,  dionin  solution.  Internally, 
the  various  iodids  or  small,  frequently  repeated  doses  of  salicylate  of 
sodium  may  be  administered. 

Various  forms  of  operative  procedure  have  been  .attempted: 
sclerotomy  and,  recently,  trephining  the  sclera,  thus  evacuating  the  sub- 
retinal  fluid;  evacuation  of  the  subretinal  fluid  by  puncture  and  aspira- 
tion, and  drainage  by  means  of  a  gold  wire;  electrolytic  puncture; 
incision  of  the  fibrous  bands  in  the  vitreous,  followed  b}'  the  injection 
of  the  vitreous  humor  of  a  rabbit  (Deutschmann) ;  resection  of  the 
sclera  (Miiller).  Subconjunctival  injections  are  valuable.  For  this 
purpose  de  Wecker  employed  a  solution  composed  of  3^^  parts  of 
gelatin  with  100  parts  of  physiologic  salt  solution.  Jocqs  advocates 
injections  of  a  saturated  solution  of  salt  in  conjunction  with  scleral 
puncture,  while  Bourgeois  recommends  a  30  per  cent,  salt  solution 
to  which  a  few  drops  of  a  5  per  cent,  solution  of  cocain  are  added.  1  c.c. 
of  the  fluid  being  injected.  Subconjunctival  injections  of  cyanid  of 
mercury  and  of  sodium  chlorid  are  also  advocated;  they  may  be 
rendered  painless  by  adding  acoin  to  the  solution.  The  author  has 
secured  a  few  favorable  results  with  scleral  puncture,  followed  by  large 
(30  minims — 1.9  c.c.)  injections  of  physiologic  salt  solution,  and  has 
not  founil  it  necessary  to  increase  the  strength  of  the  salt  solution 
beyond  4  or  5  per  cent.  During  the  treatment  the  patient  should 
remain  in  bed.  Scleral  cauterization,  followed  by  subconjunctival 
saline  injections,  has  been  employed  by  Dor,  and  j)uncture  of  the 
eyeball  with  tlic  galvanocaulery  has  Ix'oii  advocated.  With  Dmitsch- 
mann's  (jpcration  (l)is('cti<)ii  of  the  vitreous  and  retina,  with  or  without 
the  intravitreous  injection  of  animal  vitreous)  the  author  has  had  no 
experience.  Deutschmann  reports  good  results;  some  surgeons  who 
have  investigated  the  subject  are  not  in  favor  of  the  operation.  If  the 
detachment  is  (hie  to  a  tumor,  the  e\('  should  be  enucleated  (see 
page  392). 

Hemorrhages  in  the  Retina  (Apoplexy  of  the  liciiiui). — The 
appearances  of  retinal  heniorrliage  have  been  described  in  the  general 
symptom-grouping,  and  lus  they  occur  with  .so-calleil  heuiorrhagic 
retinitis  (see  page   172). 


HEMORRHAGES    IN    THE    RETINA  495 

Hemorrhages  (unassociated  with  inflammation)  may  be  in  any  of 
the  layers  of  the  retina,  or,  bm'sting  through  the  hmiting  membrane, 
the}'  may  occupy  the  vitreous  humor.  By  preference  the\^  are  found 
along  the  course  of  the  larger  vessels;  a  favorite  site  is  the  macula. 
Hemorrhages  originating  in  the  outer  sheath  of  the  optic  nerve  may 
appear  at  its  margin  and  spread  into  the  surrounding  retina,  although 
it  does  not  follow  that  such  hemorrhagic  extravasations  always  follow 
this  course. 

Hemorrhages  of  large  dimensions  and  drop-like  form  usually  mean 
an  extravasation  between  the  internal  limiting  membrane  of  the  retina 
and  the  hyaloid  membrane  of  the  vitreous,  and  they  come  from  a 
retinal  vessel.     These  subhyaloid  or  preretinal  hemorrhages  tend  to  occur 


Fig.  216. — Retinal  hemorrhages  (de  Wecker  and  Masselon). 

at  the  yellow  spot  more  than  at  other  parts  of  the  fundus.  Occasion- 
ally they  assume  a  wedge-,  bottle-shaped,  or  almost  circular  appearance, 
or  they  may  have,  as  in  an  eye  recently  examined  by  the  author,  a  long, 
roll-like  form,  and  overlie  the  sweep  of  the  retinal  vessel;  often  they  are 
semilunar  in  shape.  Except  as  the  result  of  traumatism  they  are 
exceedingly  scarce  in  young  children,  but  Harms  has  reported  one  case 
in  a  child  of  four  and  one-haK  years.  According  to  J.  Herbert  Fisher, 
the  hemorrhage  detaches  the  internal  limiting  membrane  from  the 
retinal  layers,  which  are  not  invaded,  and  occupies  the  space  thus 
formed.     It  may  break  into  the  vitreous. 

Causes.— Some  of  these  have  already  been  enumerated.  The 
following  resume,  based  upon  the  classification  of  Dimmer,  may  be 
added: 

(a)  Hemorrhages  caused  by  changes  in  the  composition  of  the 
blood  and  the  tissues  of  the  blood-vessel  walls:  Pyemia,  septicemia, 
ulcerating    endocarditis;  diseases   of   the  liver,   spleen,   kidney,    and 


496 


DISEASES    OF    THE    RETINA 


atheroma  of  the  vessels,  and  angiosclerosis  of  the  ictiual  vessel;  k>ss 
of  blood  (inenoiihaf2;ia.  heniateniesis) ;  anemia  (simple  and  pernicious); 
hemophilia,  purpura,  and  scurvy;  diabetes  and  p;out;  tuberculosis; 
malaria  and  recurrent  fever.  In  carcinoma  of  the  stomach  retinal 
hemorrhages  and  white  spots  may  resemble  those  seen  in  pernicious 
anemia.  To  this  manifestation  the  name  cachectic  rctinitix  is  some- 
times applied. 

{b)  H.emorrhages  caused  b}'  disturJjances  in  the  circulation:  Hyper- 
trophy of  the  heart  and  stenosis  of  the  valves;  thrombosis  of  the  cen- 
tral vein  of  the  retina,  and  embolism  or  throml)osis  of  the  central 
artery;  suffocation,  compression  of  the  carotid,  and  hemorrhages  in 
the  new-born,  which  ar(>  not  infrequent;  and  the  menstrual 
disturbances. 


Fig.  217. — Siilihyaloiii  luMiiorrhage. 


(c)  Hemorrhages  caused  by  sudden  alterations  of  the  intrann-ular 
tension — e.  g.,  after  iri(U>ctoniy  in  glaucoma — and  by  traumatisms. 
Among  the  latter  may  be  classed  retinal  hemorrhages  after  large  cuta- 
neous burns,  and  those  which  have  follow(>d  compn^ssion  of  tiie  thorax 
and  neck  and  fracture  of  the  skull. 

((/)  Hemoirhages  caused  i)y  certain  toxic  agiMits-c.  (/.,  phosphorus, 
chlorate  of  potassium,  serpent  virus. 

Prognosis.  This  (h'pends  ui)on  the  extent  ami  situation  of  the 
hemorrhages.  They  foiiu  an  important  piognostic  guide  of  the  disea.se 
which  has  caused  tiiem,  and  in  eldeily  persons  may  l»e  an  indication  of 
future  hemorrhages  into  the  biain.  (!laucom:i,  detaclunent  of  the 
retina, and  the  formation  of  dense  opacities  in  the  vitreous  humor  may 
be  complications. 

Treatment.  .Vll  use  <if  the  eyes  must  be  forbidden.  Locally,  a 
weak  sohilion  of  sulphate  of  eserin  may  l»e  eiiiploM-d.  especial!)  in 
elderly  people  to  check  ;uiy  lendencv  to  iiicr(>ase(l  inl  la-ociilar  picssure. 


1 


CHANGES    IN    THE    RETINAL  VESSELS    AND    THEIR    WALLS       497 


Internalh^  the  medication  must  be  governed  by  the  probable  cause. 
Frequently  cardiac  sedatives,  moderate  diaphoresis,  and  later,  altera- 
tives, such  as  iodid  of  potassium,  iodid  of  sodium,  syrup  of  hydriodic 
acid,  and  bichlorid  of  mercury,  will  be  required.  If  the  arterial 
tension  is  high,  nitroglycerin  should  be  administered.  Lactate  of  cal- 
cium may  be  tried,  but  should  not  be  used  continuously  for  more  than 
several  daj^s  at  a  time. 

Changes  in  the  Retinal  Vessels  and  Their  Walls. — Certain 
changes  in  the  retinal  vessels  due  to  vasculitis  and  perivasculitis  are 
often  seen.  These  are  characterized  bj"  the  appearance  of  white  stripes 
along  the  vessels  or,  rather,  the  vessel  walls  become  apparent  b}^  their 
conversion  into  whitish  tissue,  due  probably  to  an  infiltration  of  the 
adventitia  with  lymph-corpuscles.  This  maj'  be  so  extensive  thatTthe 
entire  set  of  vessels  is  converted  into  a  series  of  branching  white  lines. 


Fig.  218. — Extensive  retinal  vessel  disease;  periarteritis  and  periphlebitis.     Right'eye 

Such  conditions  may  be  due  to  various  inflammatory  diseases  of 
the  retina  and  optic  nerve.  Alterations  in  the  retinal  vessels  are  also 
caused  by  chronic  nephritis  and  general  arteriosclerosis,  and  present  the 
following  ophthalmoscopic  appearances: 

1.  Alterations  in  the  course  and  caliber  of  the  retinal  arteries,  mani- 
festing themselves  as  (a)  undue  tortuosity,  which  is  not  significant 
unless,  to  quote  the  words  of  ]\Ir.  Gunn,  whose  classification  is  fol- 
lowed, it  is  associated  with  other  evidence  of  disease;  (6)  alterations  in 
the  size  and  breadth  of  the  retinal  arteries,  presenting,  as  it  were,  a 
beaded  appearance. 

2.  Alterations  in  the  reflections  from,  and  the  translucency  of,  the 
walls  of  the  retinal  arteries,  manifesting  themselves  (a)  in  increased 
distinctness  of  the  central  light-streak  on  the  retinal  vessel  and  an 
unusually  light  color  of  the  entire  breadth  of  the  artery  ("silver- wire 
arteries");  (h)  loss  of  translucency,  so  that  it  is  impossible  to  see,  as  it 

32 


498  DISEASES    OF    THE    RETINA 

is  in  the  normal  state,  through  the  artery  an  underlying  vein  at  the 
point  of  crossing;  (c)  jjositive  changes  in  the  arterial  walls,  consisting 
of  whitish  stripes,  indicating  degeneration  of  the  walls  or  infiltration  of 
the  perivascular  lymph-sheaths  {perivasculitis) . 

3.  Alterations  in  the  course  and  caliber  of  the  veins,  together  with 
signs  of  mechanical  pressure,  manifesting  themselves  (a)  in  undue 
tortuosity,  which,  as  in  the  case  of  the  arteries,  is  not  significant  except 
in  the  presence  of  other  disease;  (6)  alternate  contractions  and  dilata- 
tions; (c)  an  impeded  venous  circulation  where  a  diseased  artery  crosses 
it.  The  last  is  a  sign  of  the  utmost  importance.  Ordinarily,  as  an 
artery  crosses  the  vein,  as  it  may  be  seen  by  an  examination  of  the 
normal  ej'e-ground,  there  is  no  sign  of  pressure.  If  the  walls  of  the 
artery  are  thickened  by  disease,  it  presses  upon  the  vein,  pushes  it 
aside,  or  directly  contracts  its  caliber,  so  that  beyond  the  point  of 
crossing  there  is  an  ampulliform  dilatation.  ,  (d)  Changes  in  the  venous 
walls,  precisely  as  they  occur  in  the  arteries,  so  that  whitish  stripes 
border  the  vessel,  and  are  indications  of  degeneration  in  its  walls. 
Often  associated  with  this  one  may  see  varicosities.     (See  Plate  V.) 

4.  Edema  of  the  retina,  manifesting  itself  (a)  as  a  grayish  opacity, 
which  may  be  present  in  the  immediate  neighborhood  of  the  papilla, 
or  in  spots  over  the  eye-ground  and  along  the  course  of  the  vessels, 
looking  like  a  fine  gray  haze,  or  in  little  fluff}'  islands  far  out  in  the 
periphery. 

5.  Hemorrhages,  manifesting  themselves  as  linear  extravasations 
along  the  course  of  the  vessels,  roundish  infiltrations  scattered  over 
the  fundus,  or  sometimes  in  a  drop-like  form.  All  these  changes  have 
been  described  by  Raehlmann,  Friedenwald,  Hertel,  Hirschberg, 
Foster  Moore,  the  author,  and  many  other  observers,  and  were 
especially  accurately  recorded  and  classified  by  the  late  Mr.  ISlarcus 
Gunn.  The  retinitis  of  angiosclerosis,  as  described  by  Foster  Moore,  is 
distinct  from  the  ordinary  types  of  retinal  angiosclerosis,  being  due 
to  local,  retinal  vascular  disease  and  is  not  necessarily  associated  with 
nephritis.  It  may  be  unilateral;  it  gradually  develops  from  a  comli- 
tion  of  retinal  arteriosclerosis. 

The  significance  of  these  lesions  is  of  serious  import.  In  adilition 
to  their  relation  to  nephritis,  they  may  be  the  forerunners  of  vascular 
sclerosis  of  the  brain  or  indicate  the  presence  of  disease  of  the  cerebral 
arteries.  Tlicir  subj(>cts  are  liable  to  hemorrhage  in  the  brain  ami  all 
its  conseciuences.  The  changes  which  have  been  tlescribed  are  i>f  tlie 
greatest  importance,  according  to  Foster  ^loore,  if  they  are  concerneil 
with  the  secondary  and  tertiary  branches  of  the  retinal  artery.  In- 
dentation of  a  vein  and  obstruction  of  the  l)lood-flow  at  the  point 
wh('r(!  an  artery  cro.sses  the  line  of  the  vein  are  important  signs 
of  angiosclerosis.  An  attempt  has  hecMi  made  ly  P.  ('.  Panlsley  to 
<liiTerentiate  ophthalmoscopically  l)e(ween  the  signs  of  arteriosclerosis 
and  those  due  simply  to  increased  blood  jjressure.  In  cases  of  simple 
increased  blood  pressure  the  vessels  have  (he  appeaiaiice  of  uniform 
(Hstention,  the  light   streak  is  larger  tlian  normal,  l)ut  (he  silver-wire 


Pla'ie  V. 


Changes  in  the  fundus  in  arteriosclerosis. 


EXUDATIVE    RETINITIS 


499 


appearance  in  the  arteries  is  absent;  indentation  of  the  veins  occurs 
if  ,the  arteries  are  very  tight.  In  retinal  angiosclerosis,  the  disease  is 
probably  primarily  in  the  intima,  according  to  Coats,  and  in  arteritis 
new  tissue  forms  which  encroaches  on  the  lumen  of  the  vessel,  some- 
times suggesting  a  hyaline  change.  According  to  this  observer,  irregu- 
larities of  vessel  caliber  are  due  to  endothelial  proliferation,  [and 
silver-wire  arteries  to  fibrosis.  Endothelial  proliferation  of  the  main 
artery  depends  upon  a  circulating  toxin. 

Angioid  Streaks  in  the  Retina  (Retinal  Pigment  Strice). — These 
occur  as  dark,  reddish-brown,  sometimes  almost  black  striae  lying  be- 


FiG.'219. — Angioid  streaks  in  the  retina;  large  central  semicircular  hemorrhage. 

neath  the  retinal  vessels.  They  give  the  impression  of  a  system  of 
obliterated  vessels,  as  in  a  case  recorded  bj^  the  author,  but  are  caused, 
according  to  Ward  Holden,  by  the  metamorphosis  of  hemorrhages 
diffused  in  a  linear  manner  through  the  deep  layers  of  the  retina. 
Lister  thinks  they  represent  newly  formed  vessels  which  have  pene- 
trated inflamed  tissue,  and  along  which  pigment  deposits  and  other 
exudations  are  arranged.  W.  Zentmayer  is  inclined  to  regard  the 
streaks  as  pigmented  vessels  which  are  either  of  inflammatory'  or 
congenital  origin.  Coats  suggests  that  the  streaks  arise  along  vessels, 
but  that  these  vessels  belong  to  the  choroid  rather  than  the  retina. 

Exudative  Retinitis  (Retinitis  Hemorrhagica  Externa;  Massive 
Retinal  Exudation  [Coats]).— In  this  form  of  retinal  disease,  particu- 
larly well  described  and  studied  by  George  Coats,  the  most  conspicuous 


500 


DISEASES    OF    THE    RETINA 


feature  is  a  large,  prominent  yellowish-white  circumscribed  lesion,  or 
smaller  areas  of  yellow  or  white  exudations  lying  beneath  the  retinal 
vessels.  Coats  has  investigated  several  varieties  of  the  affection, 
namely,  those  without  gross  vascular  disease,  those  with  extensive 
vascular  changes,  and  those  with  arteriovenous  communication. 
Later  he  removed  the  last-named  variety  from  his  classification  of 
massive  retinal  exudation.  Of  insidious  onset  and  slow  progress,  the 
disease  most  often  attacks  young  persons  (average  age  about  nineteen), 
and  is  more  common  among  males  than  females.  The  patients  are 
usually  in  good  health  (anemia  may  be  present),  and  their  clinical  and 
familv  histories  do  not  vield  information  as  to  the  etif>lf><rie  factor.     In 


Fig.  220. —  Massive  retinal  exudation,     l.t-fl  eye  ol  a  nirl  am-il  nineiiin. 

late  stages  of  the  disease  detachment  of  the  r(>tina,  cataract,  iritis,  and 
glaucoma  may  develo]).  The  affection  d(>peiids,  as  Coats  has  slutwii. 
n])()U  hemorrhages  in  tiie  interretinal  layers.  A  slow  organi/ation 
takes  place  with  formation  of  cicatricial  tissue  masses.  At  first  the 
choroid  remains  fice  from  pathologic  alterations,  l>ut  there  are  border- 
line cases  of  the  (hsease  charactei'ized  by  involvement  of  the  clioroid 
as  well  as  tlie  retina  in  the  form  of  ihickeiiiiig  and  roumi-i-ell  infill  ra- 
tion. ]*AU(hitive  i-elinilis  is  prohalily  ihe  result  of  local  vascular 
disease;  oj)hlhahnosc()picaII\  it  h:is  most  olten  lieen  mistaken  ior 
tuberculous  choroiditis.  I'lom  ilic  clinical  standpoint  tliis  disease 
has  been  stu(hed  in  this  couiihy  by  J- liedeiiwald,  Zent  mayer,  .lervey, 
the  aullior  and  oilier  observers.  N'erhoelf  has  made  one  pathologii- 
ex.aminat  ion. 


1^ 


OBSTRUCTION  OF  THE  CENTRAL  ARTERY  OF  THE  RETINA  501 

Aneurysms. — Aneurysm  of  the  central  retinal  artery  is  an  extreme 
rarity.  It  has  been  seen  as  a  spindle-shaped  sac,  pulsating  synchron- 
ously with  the  heart.  Miliary  aneurysms,  usually  spindle  shaped, 
have  been  noted  in  the  small  arterial  twigs  in  elderly  persons,  and  may 
be  looked  upon  as  significant  of  a  similar  condition  of  the  vessels  in 
other  organs,  especially  the  brain.  They  may  be  associated  with 
angiosclerosis,  cardiac  disease  and  nephritis.  The  student  should 
not  mistake  varicosities  in  the  veins  for  aneurysms.  Arteriovenous 
aneurysm  of  the  retina  has  been  described.  Retinitis  with  miliary 
aneurysms  is  a  term  descriptive  of  a  lesion  consisting  in  an  extensive  in- 
filtration of  the  retina  with  multiple  miliary  aneurysms,  particularly  in- 
vestigated by  Leber  and,  although  resembling  one  of  the  varieties  of 
exudative  retinitis  with  vascular  changes  (Coats),  has  been  placed 
in  a  separate  class.  All  of  the  cases  (about  15  in  number)  have  oc- 
curred in  young  males.  Friedenwald  has  studied  one  case  in  this 
country.     No  satisfactory  cause  for  this  condition  has  been  discovered. 

Angiomatosis  of  the  Retina. — This  rare  disease  has  been  ob- 
served by  Fuchs,  Goldzieher,  Darier,  and  a  few  other  observers,  but 
its  first  accurate  description  is  by  E.  von  Hippel  and  it  is  sometimes 
called  von  Hippel's  disease.  According  to  him,  the  most  prominent 
ophthalmoscopic  appearances  are  red,  spheric  formations,  with  enor- 
mous dilatation  and  tortuosity  of  one  or  more  arteries  and  the  accom- 
panying veins,  both  sets  of  vessels  having  the  same  color.  Something 
over  30  cases  are  on  record;  tuberculosis  is  suggested  as  a  cause.  Ana- 
tomic examination  reveals  diseased  retinal  vessels,  destruction  of  the 
nervous  elements,  proliferation  of  the  glia,  and  organization  of  sub- 
retinal  hemorrhage  (von  Hippel).  According  to  Meller,  primarily 
there  is  increase  of  the  neuroglia  with  secondary  vascular  changes. 
The  prognosis  as  to  vision  is  fatal;  blindness  from  secondary  glaucoma 
results. 

Obstruction  of  the  Central  Artery  of  the  Retina,  Including 
Embolism  and  Thrombosis. — Rarely  an  embolus  lodges  in  the  cen- 
tral artery  of  the  retina;  5  cases  on  record,  according  to  Coats,  namely, 
his  own  and  those  of  Harms,  Schweigger,  Manz,  and  Marple,  were  defi- 
nitely embolic  in  nature;  since  this  report  others  have  been  included 
in  the  list.  Usually  the  symptoms  recorded  in  the  following  para- 
graphs are  caused  by  thrombosis  or  by  obliterating  endarteritis. 
Leber,  however,  was  of  the  opinion  that  embolism  is  much  more  fre- 
quently the  cause  of  the  obstruction  than  the  reports  of  investigators 
would  indicate. 

Symptoms. — ^The  main  branches  of  the  artery  are  thin,  and  can  be 
followed  only  a  short  distance  over  the  edge  of  the  papilla  into  the 
retina,  and  there  is  a  diminution  in  the  number  of  ramifications.  The 
veins  are  also  contracted,  and  very  often  they  present  unequal  disten- 
tion. They  may  present  ampulliform  broadening,  alternate  contrac- 
tions and  swellings,  and  especially  a  contraction  at  the  disk,  succeeded 
by  broadening  in  the  periphery,  where  they  assume  almost  their  natural 
breadth.     Pressure  from  before  backward,  so  as  to  increase  the  intra- 


502  DISEASES    OF   THE    RETINA 

ocular  tension,  causes  a  regular  current  to  flow  through  the  vessels. 
This  consists  of  l)rokon  cylindors  of  blood,  separated  b\'  clear  spaces, 
which  move  sluggishly  along.  In  the  veins,  without  such  pressure, 
and,  it  may  be,  directly  after  the  accident,  an  intermittent  blood-stream 
is  often  visible.  The  appearance  is  not  unlike  that  produced  when  air 
is  allowed  to  mix  with  a  fluid  in  a  tube.  Occasionally  a  few  hemor- 
rhages are  seen  along  the  course  of  the  vessels. 

The  papilla  assumes  a  pallid,  grayish-white  appearance,  owing  to 
the  lack  of  blood  in  its  capillaries.  An  opacity  in  the  retina  develops, 
grayish-white  or  fog-like  in  appearance,  sometimes  permitting  the  red- 
dish tint  of  the  normal  ej'e-ground  to  shine  through  it,  and  sometimes 
being  so  opaque  that  it  is  quite  milk-liko  in  its  density.  This  occurs 
especially  in  the  neighborhood  of  the  papilla  and  in  the  macular  region, 
the  space  between  the  two  often  being  free,  although  gradually  the 
areas  meet.  The  opacity  comes  on  within  a  few  hours  after  the  acci- 
dent, or  may  be  delayed  for  a  day  or  two.  The  author  has  watched  it 
form  within  twenty  minutes  after  sudden  stoppage  of. the  central 
retinal  circulation.  It  is  due,  according  to  Coats,  not  to  edema,  but 
to  an  ischemic  necrosis. 

Characteristic  of  sudden  obstruction  of  the  arterial  circulation  is 
the  formation  in  the  macula  lutoa  (corresponding  to  the  position  of  the 
fovea)  of  a  central  red  spot,  which  resembles  a  round  hemorrhage  in 
the  midst  of  the  milky-white  area.  It  is  known  as  the  cherry-red  spot 
of  the  macula  lutea,  and  is  caused  by  the  red  color  of  the  choroid  ap- 
pearing through  the  much-thinned  retina,  and  changes  in  the  |)igment 
epithelium.  As  a  rare  phenomenon,  at  least  in  the  dark-skinned  races, 
the  usual  cherry-red  spot  has  been  replaced  by  a  coal-black  one.  The 
spot  appears  at  the  same  time  with  the  opacity  in  the  macula  lutea. 
It  is  less  likely  to  form  where  there  is  a  stoppage  of  a  branch  of  the 
retinal  artery  instead  of  one  of  the  main  trunks. 

In  the  course  of  several  weeks  there  is  a  gradual  disappearance 
of  the  retinal  opacity,  the  optic  disk  undergoes  atrophy,  and  the  retinal 
vessels  are  shrunken  or  even  converted  into  white  cords;  if  tiiere  have 
been  hemorrhages,  spots  of  degeneration  appear  at  their  positions,  and 
not  infreciueiitly  cholesterin  crystals  and  pigment  markings  may  l)e 
seen  around  the  disk  and  in  the  macula  lutea. 

Instead  of  the  main  trunk,  a  branch  may  be  obstructed,  aiul  tliis 
obstruction  is  sometimes  visible  to  the  ophthalmoscope  as  a  yellowish 
body,  but ,  more  ficfpiently,  at  one  point  of  tiie  artery  then' isaswi^liing, 
while  beyond  it  the  vessel  is  obliterated  or  its  caliber  is  nuich  reduced. 

Vision  is  lost  with  characteristic  suddenness.  Usually  preceding 
tile  hUrxhiess  there  is  temporary  obscuration  of  vision,  or  a  little  lu^ad- 
aciu!  and  giddiness,  with  ihishes  of  light,  repicsenting  a  spei-ies  of 
aura.  Periods  of  temporary  blindnes.s  lasting  from  a  few  minutes  to 
one-half  hour,  during  several  years  (in  one  of  the  .author's  cases  twelve 
years),  may  precede  the  nltiinat(>  ol)st ruction  of  the  artery.  In  ob- 
struction of  a  branch,  <in  the  nl  liei  hand.  tiuMc  may  be  very  good  acute- 
ness  of  vision.      The  |)i-eseiice  of  a  clliDri  lintd  resst  I  iua\'  be  t  he  means  of 


OBSTRUCTION  OF  THE  CENTRAL  ARTERY  OF  THE  RETINA  503 


preserving  vision.     A  rare  condition  is  obstruction  of  a  cilioretinal 
artery  (Hirsch,  Zentmayer,  F.  Krauss). 

The  field  of  vision  varies  according  to  the  extent  of  the  blocking 
of  the  circulation.  In  cases  where  the  obstruction  is  complete,  even 
light  perception  is  absent.  If  onh'  a  branch  has  been  occluded,  that 
portion  of  the  retina  which  receives  its  blood-supply  from  this  source 
will  be  paralyzed,  and  the  opposite  area  of  the  field  will  be  darkened. 
The  presence  of  a  cilioretinal  vessel  permits,  as  a  rule,  an  oval  portion 
of  the  field  of  vision  to  remain  in  the  neighborhood  of  the  fixation-point, 
but,  according  to  C.  F.  Clark,  the  evidence  is  not  sufficient  to  warrant 
the  conclusion  that  such  a  vessel  is  the  means  of  preserving  the  in- 


FiG.  221. — Small  visual  field  representing  area  of  functionating  retina   surrounding 

blind-spot. 

tegrity  of  the  papillomacular  region  of  the  retina.  Even  if  the  main 
stem  of  the  artery  is  obstructed,  a  small  portion  of  the  field  may  be 
preserved  on  the  temporal  side,  corresponding  to  an  area  on  the  nasal 
side  of  the  fovea  in  the  region  of  the  blind-spot  (Fig.  221).  An  un- 
common effect  is  a  central  scotoma,  which  may  be  due  to  obstruction 
of  the  macular  arteries;  the  scotoma  may  also  be  paracentral. 

The  intra-ocular  tension  is  sometimes  raised,  sometimes  lowered, 
and  sometimes  unaffected.  The  pupil  may  be  large  and  irresponsive  to 
light  if  the  case  is  one  of  complete  stoppage  of  the  central  artery.^ 
As  complications  there  may  be  retinal  hemorrhages,  perhaps  due  to 
associated  venous  thrombosis  (Leber),  secondary  glaucoma  and 
rarely  an  iritis. 

1  The  symptoms  which  have  been  described  refer  to  typical  cases;  a  variety  of 
exceptions  occurs. 


504  DISEASES    OF    THE    RETINA 

Causes. — The  most  frequent  causes  of  oljstruction  of  the  central 
artery  of  the  retina  are  valvular  disease  of  the  heart,  especially  f  com- 
plicated by  a  fresh  endocarditis,  and  p:pneral  arterial  sclerosis,  aneu- 
rj'sm  of  the  aorta  or  of  the  carotid.  Bright 's  disease  and  pregnancy; 
in  a  few  instances  it  has  l)een  noted  with  chorea;  also  with  anemia, 
menstrual  derangements,  recurring  epistaxis  and  diabetes.  Throm- 
botic obstruction  depends  upon  endarterial  changes,  and  alteration 
of  the  composition  of  the  blood  and  its  coagulability.  Stoppage  of 
the  central  artery  may  occur  at  almost  any  age  of  life,  and  has  been 
recorded  from  the  fifteenth  to  the  eightieth  year.  Tlie  accident 
usually  is  unilateral,  simultaneous  obstruction  of  the  central  artery 
of  each  eye  being  very  rare;  occasionally  both  eyes  are  affected,  with 
a  definite  interval  between  the  attacks.^  Blindness  with  ophthal- 
moscopic appearances  exactly  similar  to  those  caused  by  obstruction 
of  the  central  artery  has  followed  subcutaneous  injections  of  paraffin 
in  the  nasal  region  and  injections  of  bismuth  paste  into  the  accessory 
sinuses.     Fat  embolism  of  the  artery  has  also  been  reported. 

Diagnosis. — The  ophthalmoscopic  picture  just  detailed  indicates 
that  a  l)l()ck  in  the  central  retinal  circulation  has  occurred,  due  usually 
to  one  or  other  of  the  causes  already  named.  Similar  appearances  have 
been  ascribed  to  hemorrhage  into  the  sheath  of  the  optic  nerve,  to 
spasm  of  the  muscular  wall  of  the  central  artery,  and  to  thrombosis 
of  the  central  vein  so  situated  that  it  presses  uj)()n  and  occludes  the 
lumen  of  the  artery  lying  beside  it.  Schweigger  taught  that  emptiness 
of  the  arteries  was  an  important  sign  of  true  embolism. 

Some  cases  of  obstruction  of  the  central  retinal  circulation  appear 
to  be  due  to  collapse  of  the  arterial  walls,  so  that  they  come  in  con- 
tact (Hoppe).  In  these  circumstances  recovery  may  occur  sponta- 
neously or  be  brought  about  by  treatment.  While  it  is  true  that 
"there  is  at  present  no  proof  that  obstruction  may  be  caused  by 
spasm  apart  from  endarteritis"  (Coats),  the  effect  of  an  apparent 
spasm  of  the  retinal  arteries  from  the  clinical  standpoint  must  be 
conceded.  The  author  has  examined  Harbridge's  patient,  and 
watched  complete  collapse  of  the  retinal  arteries,  followed  in  four 
minutes  by  the  restoration  of  their  calil)er.  Spasm  may  be  due  to 
toxic  agents,  even  to  tobacco  (Ormond).  Iiitcnnittcut  closiiuj  of  the 
retinal  arteries,  apparently  due  to  vessel  cramp,  has  l)een  many  times 
recorded;  for  example,  with  angiosclerosis,  Raynaud's  disease,  epi- 
lepsy, and  migraine  (see  also  i:)age  401). 

Prognosis. — This  is  exceedingly  unfa\(»ral>le,  aiul  in  most  instances 
blindness  is  the  result.  Even  where  (emi)orary  improvcMuent  occurs, 
sul)se(|uent  atroph\'  of  the  nerve  is  likely  to  ensue.  In  obsl ruction  of  a 
branch  the  prognosis  is  more  favorable,  and,  as  has  been  stated,  normal 
central  vision  m:iy  be  present.     The  presence  of  a  cilioret inal  V(\^sel 

'  III  :i  certain  iiiiimIht  of  (•.iscs  (.iiO  piT  cent,  afconiiiin  to  .\.  Kiuipp),  Jiltliouuli 
all  the  ordinary  oj)litli:ilinoscopic  Hp|)L'Uianco.s  of  (>inl)olisin  of  tlu'  ccntml  nrtiTy 
of  tlif  ictinii  iiave  Im'om  present,  it  lia.s  l)een  iinpo.s.sil)Ie  to  n.ssi;jn  a  eau.se.  This 
is  particularly  true  in  cases  occurring  in  yoiini;  persons,  esjjocijilly  young  women. 


I 


THROMBOSIS   OF   THE    CENTRAL   VEIN  505 

improves  the  prognosis.  According  to  Swanzy,  in  cases  of  bilateral 
obstruction,  unless  vision  is  lost  simultaneously,  a  fair  amount  of 
vision  may  be  restored.  Glaucoma,  as  before  noted,  may  follow 
stoppage  of  the  central  retinal  artery. 

Treatment. — In  the  hope  of  restoring  the  circulation  by  reducing 
the  intra-ocular  tension,  sclerotomy,  iridectomy,  and  repeated  para- 
centesis of  the  anterior  chamber  have  been  practised  and  successes 
have  been  reported. 

Massage  of  the  eyeball  has  been  recommended,  and  in  some  cases 
has  been  followed  by  good  results.  It  should  be  given  a  faithful  trial; 
the  author  can  confirm  its  value.  With  the  massage,  inhalations  of 
nitrite  of  amyl  should  be  given.  If  massage  fails,  operation  may  be 
performed  (paracentesis  or  iridectomy,  preferably  the  former). 

Thrombosis  of  the  Central  Vein. — In  thrombosis  of  the  central 
vein  the  obstruction  practically  always  occurs  at  the  lamina  cribrosa 
and  may  be  associated  with  narrowing  of  central  artery. 

Symptoms. — ^The  ophthalmoscopic  signs  of  this  condition  may  be 
similar  to  those  described  under  Hemorrhagic  Retinitis,  of  which  it 
may  be  a  cause  (see  page  472) .  Several  grades  of  this  condition  have 
been  recorded.  The  ophthalmoscope  may  reveal  tortuosity  of  the 
vessels,  engorgement  of  veins,  and  normal  or  contracted  caliber  of 
the  arteries,  venous  pulse,  and  interrupted  venous  circulation  and 
extensive  retinal  hemorrhages;  or  there  may  be  complete  obscuration 
of  the  disk,  which  is  hidden  by  infiltrated  retina,  and  surrounded  by 
large  flame-shaped  and  sometimes  sheet-like  hemorrhages,  which 
extend  widely  over  the  fundus.  Yellowish- white  spots  or  areas  may 
appear  between  the  hemorrhages.  Thrombosis  of  the  central  veins 
and  retinal  angiosclerosis  may  be  coincident  and  obstruction  (partial) 
of  the  central  artery  or  one  of  its  branches  may  also  occur.  Instead 
of  the  main  trunk,  one  of  its  branches  may  be  thrombosed,  and  the 
ophthalmoscopic  appearances  confined  to  the  area  which  it  drains 
(Fig.  222).  Vision  is  much  reduced,  a  central  scotoma  may  be 
present.  Sometimes  the  peripheral  field  is  uncontracted;  in  other 
cases  pronounced  defects  are  discoverable  indicating  implication  of  a 
retinal  artery. 

Causes. — It  occurs  with  cardiac  disease,  arteriosclerosis,  nephritis, 
diabetes,  rheumatism,  gout;  occasionally  with  chlorotic  anemia  and 
infectious  diseases.  Sometimes  a  history  of  antecedent  phlebitis  of  the 
extremities  is  obtained  as  in  several  female  patients  under  the  author's 
care.  In  a  certain  number  of  cases  no  definite  somatic  malady  can  be 
found — it  is  a  local  disease. 

Prognosis. — If  the  thrombosis  is  in  the  central  vein,  hope  of  res- 
toration of  vision  practically  must  be  abandoned;  in  obstruction  of  a 
branch  the  prognosis  is  more  favorable.  A  secondary  glaucoma,  some- 
times developing  acutely,  is  not  an  uncommon  complication,  due  to 
obstruction  of  the  filtering  area  by  an  albuminous  exudate.  This 
complication  must  always  be  feared.  If  it  develops  treatment  is  un- 
satisfactory and  usually  the  eye  passes  into  a  stage  of  so-called  absolute 


506 


DISEASES    OF   THE    RETINA 


glaucoma  (page  407).  Retinal  vein  thrombosis  in  a  definite  number 
of  cases  appears  to  be  an  indication  of  future  cerebral  hemorrhage. 
Iritis  with  the  formation  of  fibrovascular  membrane  has  been  observed. 

Treatment.— This  depends  upon  the  general  condition  and  the 
patients  with  central  vein  thrombosis  should  be  thoroughly  studied 
from  all  standpoints  and  treatment  directed  according  to  the  results 
of  the  examination.  Focal  infection  in  the  teeth  and  tonsils  should 
be  eliminated.  Other  things  being  equal,  iodids  and  syrup  of  hydriodic 
acid  may  be  administered.  Diaphoresis  may  be  tried;  mydriatics 
should  not  be  used  lest  they  cause  glaucoma;  indeed  it  is  proper  to 
use  miotics  as  part  of  the  routine  treatment. 

Traumatisms  of  the  Retina. — Under  this  general  term  may  be 
included  traumatic  anesthesia,  traumatic  amblyopia,  traumatic  per- 


FiG.  222. — Thrombosis  of  a  reliual  vein. 


forations  of  \\\c  macula  lutea,  dotachnient.  and  lupture.  There  are 
no  characteristic  symjjtoms  common  to  all  varieties,  hut  pain  and  dis- 
turbance of  vision,  in  i)art  due  to  the  liirect  injury  and  in  part  to  a 
transient  astigmatism,  are  likely  to  be  present. 

1.  Traumatic  anesthesia  of  the  retina  is  the  name  proposed  by 
Leber  to  descrilx'  effects  of  a  blow  upon  the  ej'c  without  discoverable 
oj)hthaliiioscopic  changes,  but  with  consideral)le  defect  in  vision  and 
contraction  of  the  \usual  field-  results,  moreover,  which  may  remain 
unchanged  for  a  long  time,  or,  indeed,  never  entirely  pass  away. 

The  treatment  is  rest  and  the  use  of  strychnin  internally,  or  by  hy- 
podermic medication. 

2.  Traumatic  ainhlyoina  (cdniniolia  rditnv;  edema  of  the  retina)  is  a 
condition  also  arising  from  nn  injniy.  especially  a  blow  from  a  ball, 
cork,  or  similar  body,  and  is  attended  by   the  following  symptoms: 


TRAUMATISMS    OF    THE    RETINA 


507 


Hyperemia  of  the  globe  marking  the  position  of  contact  of  the  missile; 
clear  media;  and  gray  opalescence  of  the  retina,  especially  in  the 
macular  region,  but  also  around  the  papilla,  which  may  be  somewhat 
hyperemic.  If  the  retina  under  the  point  of  contact  is  visible,  this 
also  may  exhibit  the  white  infiltration.  In  addition,  several  pale- 
yellowish  spots,  and,  occasionally,  small  hemorrhages  may  be  present. 
The  vessels  are  unchanged,  or,  in  some  instances,  are  contracted 
(arteries)  or  distended  (veins)  and  pass  over  the  gray  area.  A  central 
scotoma  may  exist. 

An  interesting  complication  is  the  development  of  a  transitory 
astigmatism,  which  helps  to  reduce  the  visual  acuteness. 


FiQ.  223. — Hole  in  macula  and  rupture  of  choroid  after  a  blow  on  eye  (patient  in  the 

University  Hospital). 

The  gray  infiltration  forms  quickly  and  is  also  absorbed  with  rapid- 
ity, usually  having  subsided  at  the  end  of  two  or  three  days,  although 
the  visual  defect  may  last  for  longer  periods.  Decided  retinocho- 
roiditis,  the  result  of  concussion,  may  occur,  and  this  fact  should  be 
remembered  in  investigating  old  cases  of  choroidal  disease  presenting 
themselves  with  meager  history.  According  to  Fuchs,  changes  in  the 
macula  after  contusion  may  be  due  to  inflammatory  edema  as  the 
result  of  a  low-grade  inflammation  of  the  ciliary  region.  The  lesions 
produced  by  concussion  of  the  eyeball  during  warfare,  as  noted  so 
frequently  during  the  past  war,  occur  as  the  result  of  concussion  at  a 
distance  (explosion  of  a  shell) ,  by  transmission  of  concussion  through 
the  bony  facial  structures,  or  by  impact  of  a  missile. 


508 


DISEASES    OF   THE    RETINA 


The  commotio  retinoB  produced  l)y  siicli  war  injuries  differs  some- 
what from  the  type  common  in  civihan  life  described  above,  in  the 
presence  of  more  numerous  hemorrhages,  the  yellow  tint  of  the 
so-called  retinal  haze,  its  longer  duration  and  more  circumscribed 
character. 

An  interesting  but  evanescent  picture  has  been  observed  and 
particularly  described  by  Colonel  Lister  in  the  later  stages  of  commotio 
retinae,  after  disappearance  of  the  haze;  namely,  peculiar  strise  in  the 
vicinity  of  the  macula,  almost  certainly  due  to  the  wrinkling  of  the 
swollen  retinal  lavers. 


Fig.  224. — Traumatic  detachment  of  the  retina  and  chorioretinal  rupture. 


In  the  "grossly  concussioncd  fundus,"  in  tlu>  early  stag(\s  tliere 
are  widespread  clouds  of  iieniorrhage,  many  gU^aniing  and  glistening 
white  particles,  which  gradually  fade,  l)econu>  converted  into  fil)r()us 
tissue,  and  represent  originally  patches  of  coagulation  necrosis  from 
rupture  of  retinal  and  choroidal  vessels  (Lister). 

The  trcdtmiiU  of  ordinary  conunotio  retinjp  consists  in  keeping  \\\o 
pupil  dilated  with  atropin  and  covering  tlu^  injured  (\ve  with  a  shade  or 
dark  glass,  all  use  of  tiie  uninjured  organ  l)eing  forl)idden. 

3.  Traumatic  Perforations  of  the  Macula  Lutea. — liaab  called 
attention  to  the  fact  that  a  contusion  or  concussion  injiuy  of  the  eye 
may  cause  a  round  hole  in  liic  macula  about  half  the  si/e  of  the  surface 
of  the  optic  disk,  surrounded  \>\  a  gray  ling.  The  l)otlom  of  the  hol(>  is 
of  reddish  color,  wit  h  a  si  ippling  of  white  .and  led.  !•'.  M.  ( )gilvie,  who 
calls  t  he  all'ecl  ion  "holes  in  t  he  macula,"  points  out  t  h.at  t  hcsc  pcrfora- 


RETINAL  CHANGES  FROM  THE  EFFECT  OF  SUNLIGHT   509 

tions  are  the  immediate  and  direct  result  of  the  injury.  In  his  observa- 
tions these  were  represented  by  areas  depressed  below  the  level  of  the 
surrounding  retina,  of  a  deep-red  color,  and  sharply  margined  by  clean- 
cut  edges.  In  some  cases  the  retina  is  detached;  in  others  it  is  not. 
A  central  scotoma  may  exist.  Other  signs  of  injury  may  be  present 
in  the  eye-ground — for  example,  rupture  of  the  choroid  (Fig.  507). 
This  "hole"  in  the  macula  is  produced  by  an  edema  of  the  retina  at 
the  posterior  pole  (Coats).  Traumatic  "holes  in  the  macula"  are  not 
of  very  uncommon  occurrence  in  civilian  practice;  numbers  of  them 
were  observed  during  the  past  war,  sometimes  as  the  sole  lesion,  more 
often  in  association  with  extensive  fundus  lesions,  particularly  rup- 
tures of  the  choroid  and  retina. 

4.  Detachment  of  the  retina  after  injury  has  been  mentioned  (see 
page  491). 

5.  Rupture  of  the  Retina. — Rupture,  uncomplicated  by  choroidal 
fissure  the  result  of  injury,  is  a  rare  accident,  and  might  be  recognized 
by  observing  the  fraj^ed  edges  of  the  tear  and  seeing  the  exposed 
choroidal  tissue.  Long  describes  such  an  occurrence  following  a  fall 
upon  the  back  of  the  head. 

Purtscher  has  described  a  fundus  lesion  after  fracture  and  trauma- 
tisms of  the  skull,  to  which  he  gives  the  name  angiopathica  traumatica 
retince.  The  ophthalmoscopic  picture  consists  in  the  presence  of 
shining  white  patches,  chiefly  associated  with  the  veins;  hemorrhages 
ma}'  also  occur.  These  patches  are  supposed  to  be  due  to  cerebro- 
spinal fluid  which  has  been  forced  into  the  retinal  perivascular  lymph- 
spaces.  To  this  condition  Korber  applies  the  term  lymyhorrhagia  of 
the  fundus. 

Retinal  Changes  from  the  Effect  of  Sunlight  (Solar  Retinitis) 
and  Electric  Light  (Electric  Retinitis). — It  has  been  experimentally 
proved  that  retinal  changes  can  be  produced  in  animals'  eyes  b}^  con- 
centrating upon  them  the  rays  of  the  sun.  Clinically,  analogous 
disturbances  have  been  found  in  the  human  retina  after  exposure  to 
intense  light,  most  frequently  in  those  who,  with  unprotected  eyes,  have 
watched  an  eclipse  of  the  sun  (eclipse  blindness).  Similar  conditions 
are  caused  by  intense  electric  light,  especially  among  those  engaged  in 
electric  welding. 

The  symptoms  are:  Persistence  of  an  after-image  or,  later,  a  dark 
spot  in  the  field  of  vision  (positive  scotoma) ;  distortion  of  objects,  and 
evidences  of  slight  retinitis  or  retinochoroiditis  in  the  macular  region. 
Thus,  there  may  be  a  maroon-colored  area  with  a  central  gray  patch, 
and  numerous  faint Ij^  marked  yellowish- white  dots.  A  cherr^'-red  spot 
has  been  detected  by  Ischreyt  and  a  definite  "hole  in  the  macula"  has 
been  described. 

Decided  improvement  is  not  infrequent,  but  complete  recovery^is 
exceptional  (Mackay);  hence  prognosis  must  be  guarded.  The  cen- 
tral scotoma  may  be  permanent  (Duane) ;  ring-shaped  scotoma  has 
also  been  observed.  Degeneration  of  the  papillomacular  bundle  may 
occur  (E.  T.  Collins). 


510  DISEASES    OF   THE    RETINA 

The  treatment  is  that  suited  to  retinochoroiditis.  The  preventive 
treatment  consists  in  wearing  suitable  colored  glasses — yellow  glass  or 
a  combination  of  blue  and  red,  or,  as  in  Sheffield,  several  layers  of  ruby 
glass. 

Glioma  of  the  Retina. — This  isamalignant  growth  of  the  retina, 
and  is  a  soft,  vascular  tumor,  made  up  of  small  round,  deeply  staining 
cells,  many  of  them  containing  long  protoplasmic  processes.  They 
form  thick  mantles  of  well-preserved  cells  around  the  thickened  blood- 
vessels, the  cells  between  the  mantles  staining  poorly  and  undergoing 
calcareous  degeneration.  In  many  of  these  neoplasms  peculiar  rosettes 
have  been  described  by  Flexner,  Wintersteiner,  and  others,  which  are 
composed  of  elements  resembling  the  rod  and  cone  visual  cells,  and 
for  these  growths  the  name  neuro-epithelioma  has  been  suggested. 

According  to  Alt  the  rosette  formation  is 
due  to  the  growing  of  tumor-cells  around  a 
tissue  enclosure,  and  not  to  rudimentary 
rods  and  cones,  and  Ginsberg  believes  they 
correspond  to  cells  of  the  rudimentary' 
retina,  which  are  not  differentiated  into 
spongioblasts  and  neuroblasts.  Glioma 
usually  arises  from  the  inner  retinal  layers; 
^Su  >y^       ^^^^  frequently  from  the  outer  retinal  layer. 

/►^  ^•^  According  to  Leber,  it  may  develop  from 

various  layers  not  only  in  different  eyes, 
but  in  the  same  eye  (Parsons).     Exactly 
how    glioma    originates    is    not    certainly 
Fio.  225. — Glioma  of  retina     known,  but  probablv  in  fetal  retinal  cells, 
(^pa^^ent  in  the  University  Ho8-  According  to  the  direction  which  the 

growth  takes,  it  has  been  described  by 
systematic  writers  as  glioma  endophytum  and  glioma  cxophytu7n.  In 
the  former  the  vitreous  chamber  is  occupied  by  the  growth;  in  the 
latter,  it  lies  between  the  retina  and  choroid. 

The  tumor  is  usually  of  a  light-graj'  or  grayish-red  color.  It  is 
subject  to  various  degenerative  changes — fatty,  cheesy,  and  calcareous 
— and  tends,  on  the  one  hand,  to  invade  the  orbit,  involve  the  optic 
nerve,  and  travel  bj'  the  waj'  of  its  sheath  to  the  brain,  and,  on  the 
other,  to  pass  forward,  bursting  through  the  sclera  and  cornea. 
Recurrence  in  loco  after  extirpation  may  occur,  and  metastases, 
especially  in  the  cranial  and  facial  bones  antl  the  brain,  may  take 
place.  They  also  occur,  according  to  F.  M.  Wilson  and  E.  S.  Thom- 
son, in  the  lymph-glands,  parotid,  liver,  ovaries,  kitlnoys,  spleen,  lungs, 
and  spine.  Glioma  may  cause  changes  in  and  invade  tissues  of  the 
eye  other  than  the  rc^tina:  the  vitreous,  choroid,  iris,  ciliary  body,  and 
anterior  chambci". 

Like  sarcoma  of  the  choroid,  glioma  passes  through  si^veral  stages. 
In  the  first,  there  are  no  signs  of  irritation,  the  media  are  clear,  the 
pupil  is  dilated,  and  often  the  growth  produces  a  whitish  reflection 
which  has  given   rise  to  the  designation  amaurotic  cat^s  eye  (stn*  also 


W 


GLIOMA    OF    THE    RETINA 


511 


page  385).  As  the  disease  progresses  symptoms  of  irritation  and  in- 
crease in  the  size  and  tension  of  the  globe  become  manifest,  and  the 
process  begins  to  involve  the  optic  nerve.  Finally,  the  tumor  bursts 
from  its  bounds,  perforates  the  globe  at  its  corneoscleral  junction, 
grows  rapidly,  involving  the  orbit  and  neighboring  temporal  regions, 
and  presents  a  huge  vascular  mass,  to  which,  in  former  times,  the  name 
fungus  hoeniatodes  was  applied. 

Glioma  of  the  retina  is  probably  always  congenital.    It  may  appar- 
entlv  occur  as  late  as  the  fifteenth  year  (one  case  in  a  girl  of  20  [C. 


Fig.  226. — Recurrence  of  glioma,  forming  the  so-called  fungus  hsematodes  (from  a 
patient  in  the  Philadelphia  General  Hospital  under  the  care  of  Dr.  Hearn.  Photograph 
by  Dr.  Pfahler). 

Maghy]),  but  in  such  circumstances  it  is  probable  that  the  growth  has 
been  present,  but  has  remained  quiescent.  In  Berrisford's  report  on 
42  cases  the  tumor  was  observed  at  birth  in  3,  within  the  first  year  in 
9,  during  the  second  year  in  6,  during  the  third  year  in  3,  during  the 
fourth  year  in  4,  during  the  fifth  year  in  3,  and  during  the  sixth  year 
in  2.  It  is  not  a  common  affection.  Hereditary  glioma  has  been  re- 
ported (Hill  Griffith,  Traquair).  Several  members  of  the  same  family 
may  be  affected.  One  or  both  eyes  may  be  involved  (bilateral  in 
about  20  per  cent,  of  the  cases  [A.  Knapp]). 

Diagnosis. — The  following  conditions,  according  to  E.  T.  Collins, 
may  be  mistaken  for  glioma:  Persistence  of  the  posterior  part  of  the 
fetal  fibrovascular  sheath  of  the  lens ;  masses  of  tubercle  in  the  choroid ; 


512  DISEASES    OF   THE    RETINA 

inflammatory  or  i)uiulent  efifusion  into  the  vitreous  following  retinitis 
or  cyclitis,  usually  with  detachment  of  the  retina  (see  also  Pseudo- 
fjlionia,  page  4ol).  Circinate  retinitis  (white  degeneration  of  the 
retina),  according  to  de  Wecker,  has  been  mistaken  for  glioma.  The 
author  and  E.  A.  Shumway  have  recorded  a  case  of  detachment  of  the 
retina  with  extensive  dropsical  degeneration  of  the  rod  and  cone  visual 
cells  which  exactly  simulated  glioma.  In  glioma  the  anterior  chamber 
is  uniformly  shallow;  in  inflanunatory  exudations  into  the  vitreous  the 
chamber  is  deepened  at  its  periphery  (retraction  of  iris)  and  shallow 
at  its  center  (bulging  of  pupillary  border).  Synechiae  are  occasitnally 
present  in  glioma.  Tension  is  usually  increased  in  glioma,  but  may 
be  minus;  rarely  the  tension  is  elevated  in  pseudoglioma.  In  case  of 
doubt  the  eye  should  be  enucleated.  Glioma  may  occur  in  a  shrunken 
eye  (about  21  cases  on  record  [Berrisford]). 

Sarcoma  of  the  choroid  is  differentiated  from  glioma  by  the  fact 
that  the  former  usually  occurs  at  a  later  period  of  life,  and  that  in  the 
earlier  stages  of  each  affection  the  ophthalmoscopic  fintlings  are  differ- 
ent. In  glioma  the  tumor  is  seen  to  involve  the  retinal  structure,  which 
does  not,  as  in  sarcoma,  merely  act  as  a  covering  to  the  growth.  Un- 
like sarcoma,  glioma  is  never  pigmented. 

Prognosis. — This  is  unfavorable,  and  if  the  disease  has  involved  the 
optic  nerve  or  bursts  from  its  bounds,  it  is  fatal.  Although  so-called 
spontaneous  cure  has  been  observed  (Lindenfield) ,  as  an  almost  inva- 
riable rule  unmolested  glioma  causes  death.  Numbers  of  recoveries 
after  proper  enucleation  are  on  record,  and  an  opinion  must  be  based 
on  the  extent  of  the  disease,  the  condition  of  the  optic  nerve  being  the 
most  important  element  in  the  prognosis.  According  to  Hirschberg,  a 
favorable  prognosis  may  be  given  if  the  tumor  has  not  passed  the  limits 
of  the  retina,  and  if  the  time  elapsing  since  the  first  appearance  of  the 
growth  has  not  exceeded  ten  weeks.  Recurrence  is  rare  after  three 
years  of  immunity.  In  a  number  of  fatal  cases  which  have  been  ana- 
h'zed  (Lawford,  Collins)  the  optic  nerve  was  unaffected  in  only  four. 
In  unfavorable  circumstances  recurrence  in  the  orbit  occurs,  with  ex- 
tension to  the  brain,  and,  more  rarely,  metastasis  to  a  distant  organ. 

Treatment. — Thorough  enucleation,  with  division  of  the  optic 
nerve  as  far  back  as  possible,  is  the  only  surgical  treatment.  In 
several  instances  both  eyes  have  been  removed,  anil  recovery  after 
such  procedure  has  been  recorded — for  example,  by  Simeon  8nell. 
Recently  x-rays  and  radium  have  been  used  in  the  tn^atment  of 
glioma,  and  there  is  evidence  that  the  growth  may  be  clici'kcd  by  this 
means.  It  is  important  that  tlu^  first  dosage  sliould  be  as  large  iis 
safety  permits.  However,  even  with  sluiiikiiig  of  the  glolx*  metas- 
tasis may  occur. 

Subretinal  Cysticerciis.  'IMiis,  Hke  the  presence  of  the  same 
I)arasite  in  the  vitreous,  is  exceedingly  uiicoimiDu  in  this  i-oiiiitry  (see 
also  page  458). 

Cysts  of  the  Retina. — Small  cysts  or  cystic  spaces  due,  prol)ably, 
to  arteiiosclerosis  of  the  retinal  eapillaries  are  not  infrecniently  found 


SYMMETRIC  CHANGES  AT  THE  MACULA  LUTEA  IN  INFANCY  513 

in  the  eyes  of  old  persons  just  behind  the  ora  serrata  (E.  T.  CoDins). 
Cysts  are  also  found  in  the  detached  retinas  of  blind  eyes,  where  they 
may  be  multiple.  They  may  commence  in  the  degenerated  retina,  or 
be  due  to  the  adhesion  of  folds  of  this  membrane  (Parsons).  Some- 
times they  are  visible  with  the  ophthalmoscope.  In  a  patient  under 
the  author's  care  a  large  retinal  cyst  springs  from  the  upper  part  of  an 
inferior  detachment  of  the  retina,  leans  over  and  partially  obscures 
the  disk.  G.  S.  Derby  describes  a  similar  cyst.  Meyer  Wiener  and 
the  author  observed,  clinically,  in  a  young  soldier  ophthalmoscopic 
appearances  which  were  reported  as  congenital  cysts  in  relation 
with  the  retina  (Fig.  227). 


Fig.  227. — Congenital  multilocular  cysts  in  relation  with  the  retina,  and  associated 
with  quiescent  pigmentary  retino-choroiditis  (from  a  patient  at  Fort  Oglethorpe,  Ga.) 


Symmetric  Changes  at  the  Macula  Lutea  in  Infancy. — This 
disease,  which  occurs  almost  always  in  children  of  Hebrew  parentage 
and  begins  from  the  third  to  the  sixth  month  of  life,  is  also  known  as 
"amaurotic  family  idiocy"  (a  name  given  by  B.  Sachs) ;  it  was  first  de- 
scribed by  Waren  Tay,  and  consists  of  a  grayish- white  zone  about  the 
size  of  the  papilla  in  each  macular  region,  with  a  brownish  or  cherry-red 
spot  in  the  center,  closely  resembling  the  appearances  seen  in  obstruc- 
tion of  the  central  artery.  At  first  the  remainder  of  the  fundus  is 
normal,  but  later  the  optic  disks  undergo  atrophy.  Kingdon  has 
thus  summarized  the  general  clinical  signs:  muscular  enfeeblement, 
apathy,  mental  weakness,  and  gradual  loss  of  sight.  Death  occurs  in 
from  one  to  two  years.  The  autopsies  show  a  change  in  the  pyramidal 
cells  of  the  cortex  and  degeneration  of  the  cord.  According  to  Sachs, 
this  is  an  arrest  of  development.     Ward  Holden,  by  Nissl's  method, 


514 


DISEASES   OF   THE    RETINA 


has  shown  that  there  is  degeneration  of  the  retinal  gangUon  cells,  and 
his  results  have  been  confirmed  by  Shumway  and  others.  Verhoeff 
attributes  the  dark  spot  in  the  macula  to  contrast;  no  edema  or  hole 
was  found  in  this  region.  The  ocular  conditions  of  this  disease  are 
merely,  as  Sachs  insists,  one  symptom  of  a  family  affection.  Syphilis 
is  not  a  cause  of  the  disease. 

Family  Cerebral  Degeneration  with  Macular  Changes. — 
This  affection,  first  described  by  11.  D.  Batten  and  named  by  (Jatman 
"maculocerebral  degeneration"  (familial),  presents  itself  in  two  forms: 
(a)  The  maculocerebral  tj'pe,  both  retina  and  brain  being  affected, 
and  (b)  the  macular  type,  the  lesions  being  confined  to  the  retina.     It 


Fig.  228. — Changes  at  the  macula  lutea  in  amaurotic  family  idiocy  (from  a  patient  in 

the  University  Hospit.il). 


develops  at  a  later  age  than  family  amaurotic  idiocy,  and  is  not  race 
selective.  In  the  first  type  the  disease  begins  usually  about  the  sixth 
year  of  life  and  is  characterized  by  macular  pigmentation,  progressive 
blindness,  progressive  paralysis,  and  dementia  (Batten  and  Mayou). 
In  the  second  ty])e  tlie  pei'iod  of  dev('lo])nii'nl  is  d(>lnycd  ami  l>egins 
about  tli(!  thirteentii  year,  ami  (he  central  nervous  .system  is  not  af- 
fected. Such  cases  hiivc  Ixmmi  describcil  l)y  Stargardt  as  "progressive* 
family  degeneration  in  the  maculai-  icgion."  Brown  Puscy's  investi- 
gations of  this  type  of  tlic  (Useasc  suggest  to  him  it  may  be  an  expres- 
sion of  caily  aitciiosclcrosis.  These  and  alHi'd  lesions  have  been 
discussed    by    (!irtdi<l    iiiidri'    the    title   of   ".hucnile  Tx  jtes  nf   .\niau- 


SENILE    MACULAR   ATROPHY    OF    THE    RETINA  515 

rotic  Family  Idiocy,"  and  by  Darier  as  "Progressive  Familial  Macular 
Degeneration.'' 

Leber  has  described  a  variety  of  tapeto-retinal  degeneration,  bilateral 
and  occurring  usually  in  several  members  of  the  same  family.  There 
is  a  central  form  with  changes  (white  spots  and  pigment  grains)  con- 
fined to  the  maculo-papillary  region,  and  a  diffuse  form  with  wide- 
spread pigment  changes.  According  to  the  age  at  which  the  disease 
develops  it  is  denominated  infantile  or  juvenile.  This  affection  is  a 
frequent  cause  of  congenital  blindness.  Sometimes  the  central  typ^e 
is  delayed  until  middle  life.  The  affection  may  be  associated  with  cere- 
bral degeneration  resulting  in  idiocy,  but  must  not  to  be  confounded  with 
amaurotic  family  idiocy  (page  513).  This  ocular  disorder  probably 
belongs  to,  and  should  be  classified  with,  the  group  of  pigmentary  de- 
generations of  the  retina  (page  487) . 

Senile  Macular  Atrophy  of  the  Retina. — Various  types  of  cen- 
tral or  macular  retinochoroiditis  and  degeneration  have  already  been 
described,  and  it  is  not  uncommon  to  find  in  the  eyes  of  old  persons,  in 
the  macular  regions,  areas  of  yellow-white  spots  interspersed  with  pig- 
ment dots  and  small  hemorrhages,  or  irregular  areas  of  erosion  which 
may  go  on  to  atrophj^  of  the  elements  and  pigment  heaping.  Haab, 
however,  has  called  attention  to  a  pure  retinal  senile  affection  consist- 
ing of  yellowish-red  or  whitish,  or  else  darkly  pigmented  spots,  the 
rest  of  the  eye-ground  being  normal,  and  Harms,  by  microscopic  inves- 
tigation, demonstrated  that  the  lesions  depend  upon  an  atrophy  and 
disappearance  of  the  involved  tissues,  affecting  chiefly  the  neuro- 
epithelial layer.  The  pigment  epithelium  is  much  altered,  but  the 
choroid  is  practically  not  affected. 

Kuhnt,  Haab,  and  the  author  have  described  a  senile  macular 
affection  (retinitis  atrophicans  centralis),  probably  belonging  to  this 
class,  which  in  all  particulars  in  its  ophthalmoscopic  appearances  re- 
sembles the  lesion  known  as  traumatic  perforation,  or  "hole"  of  the 
macula  (see  page  508).  It  may  be  caused  by  retinal  vascular  disease, 
and  a  similar  appearance  may  arise  as  the  result  of  a  non-traumatic 
iridocyclitis  or  from  a  toxin.  Indeed,  Fuchs  has  shown  that  hole- 
formation  in  the  macula  may  occur  in  a  variety  of  conditions;  for 
example,  iridochoroiditis,  neuroretinitis,  retinal  detachment,  and 
retinitis  pigmentosa. 

These  macular  changes  do  not  respond  to  treatment. 


CHAPTER  XVI 
DISEASES  OF  THE  OPTIC  NERVE 

Congenital  Anomalies. — Opaque  or  Medullated  Nerve-j&bers. — 
In  the  normal  oye  the  fibers  of  the  optic  nerve  cease  to  be  invested  with 
a  ine(hiHarv  sheath  at  the  himina  cribrosa,  and  consequently  the  axis- 
cylinders,  which  are  distributed  to  the  retina,  are  transparent.  As  an 
anomalous  condition,  sometimes  l)ilateral,  but  more  frequently  only  in 
one  eye,  the  medullary  sheaths  reappear  at  the  upper  or  lower  margin 
of  the  disk  as  a  dull  or  glistening  bluish-white  patch,  which  extends  for 
a  variable  distance  out  into  the  retina,  and  ends  in  a  somewhat  feathery 
or  fan-shaped  margin.  I'sually  the  retinal  vessels  are  hidden  by  the 
patch,  but  reappear  again  on  its  distal  side. 

This  plaque  may  be  a  single  one  above  or  below,  or  it  may  appear 
both  above  and  below  the  disk,  more  rarely  on  the  nasal  side,  and  very 
exceptionally  upon  the  temporal  margin.  The  size  varies  from  a  small 
expansion  to  a  huge  sweep  of  white  tissu(%  continuous  al>ove  and  below 
with  margins  of  disk,  and  taking  somewhat  the  general  direction  of  the 
vessels,  which  are  wholly  or  in  part  concealed.  Opaque  nerve-fibers 
of  the  retina  at  a  considerable  distance  from  the  disk  have  been  re- 
corded l)y  Randall,  Nettlcship,  Arnold  Lawson,  and  other  observers. 

This  condition  produces  no  change  in  vision  except  an  increase  in 
the  size  of  the  normal  blind-spot,  and  should  not  be  mistaken  by  the 
beginner  for  pathologic  lesions — for  example,  an  atrophy  of  the  retina 
and  {'horoid,  or  a  l)ank  of  fatty  degeneration  as  it  occurs  in  r(>tinitis 
albuminui-ica. 

Coloboma  of  the  Sheath  of  the  Optic  Nerve.  This  congenital 
anomaly  is  characterized  by  an  apparent  augmentation  of  tiie  surface 
of  the  disk  and  an  excavation  of  the  papilla  backward  and  downward, 
"^rhe  pcii])ji('ry  is  usually  bounded  l)y  pigment  massing.  Theic  is  an 
une(iual  division  of  th(»  retinal  vessels,  which  are  first  seen  as  they  bend 
over  the  margin  of  the  excavation.  It  is  a  rare  anomaly,  and  has  bi>en 
mistaken  for  posterior  staphyloma.  It  depends  u|)(mi  inipeit'ect  ciosuic 
of  the  fetal  fissure. 

Irregularities  in  the  Disk.  Instead  of  its  usual  round  or  oval  shape, 
the  disk  may  be  markedly  iri'egular  in  outline,  one  side  being  occa- 
sionally at  an  appai(Mitl\-  lower  level  than  the  other,  oi"  it  may  pri'senl 
a  gibbous  appearance.  ('oncjvniUil  liiijmvntaiion  oj tin  optic  inrir-fihcrs, 
most  intense  in  the  position  of  the  i)hysiologic  excavation,  has  occji- 
sionally  been  described;  the  pigment  may  exist  as  a  small  s|)ot  or  I'over 
an  ;i|-ea  one-fifth  of  the  size  of  the  disk.  Soinelinies  it  e\;ictl\'  sur- 
rounds t  he  exit   of  a  xcssel. 

When  the  ner\'e-liead  fails  to  lit  the  clioididal  .aperture  accuiatel\  . 
a  space  is  sometimes  formed,   usu;ill\'  crescent  ic,   known  as  a  "cone" 


[hyperemia  of  the  nerve-head 


517 


or  "conus."  This  generally  is  seen  at  the  outer  side  of  the  papilla, 
but  also  inward,  below,  and  verj-  rarel}'  above  (see  also  page  137).  It 
should  not  be  confused  with  the  atrophy  of  the  choroid  seen  in  myopic 
eyes,  to  which  the  name  -posterior  staphyloma  is  given  (see  page  139), 
nor  with  the  crescents  of  choroiditis  seen  in  astigmatic  and  stretching 
eyes,  in  which  the  scleral  ring  broadens  out  into  a  s'emi-atrophic  area 
of  disturbed  choroid,  usually  bounded  by  an  irregular  pigment  line, 
and  most  commonly  developed  at  the  temporal  side  of  the  disk.  Con- 
genital inferior  crescent  or  conus  is  caused,  according  to  Elschnig,  by  a 
pulling  away  of  the  choroid  from  the  disk  margin.  The  affected  eyes 
are  usually  astigmatic. 


Fig.  229. 


lis  optic  neuritis. 


Shreds  of  Tissue  on  the  Disk. — These  appear  as  glistening  white 
patches  of  tissue,  sometimes  almost  transparent,  at  other  times  thicker 
and  more  opaque,  either  complete^  or  partially  hiding  the  vessels. 
Occasionally  there  is  a  white  membrane  more  or  less  completely  cover- 
ing the  disk. 

Such  appearances  probably  represent  remains  of  the  hyaloid  artery 
or  of  its  adventitious  coat. 

Hyperemia  of  the  Nerve=head  {Congestion  of  the  Disk). — The 
color  of  the  intra-ocular  end  of  the  optic  nerve  varies  considerably,  and 
it  is  not  accurate  to  describe  a  nerve-head  as  congested  if  it  simply  is 
redder  than  usual. 


518  DISEASES    OF   THE    OPTIC   NERVE 

As  Gowers  pointed  out,  the  term  simple  congestion  is  applicable 
when  the  papilla  presents  a  dull  red  or  brick-dust  hue,  which  shades 
almost  imperceptibly,  through  a  blurred  margin,  into  the  general 
red  color  of  the  fundus;  when  it  is  more  marked  in  one  eye  than  in  the 
other,  the  latter  serving  as  a  picture  for  comparison;  when  at  some 
antecedent  examination  the  same  optic  disk  has  presented  a  more 
natural  color;  and  when  its  borders  are  obscured,  but  not  hidden. 

In  other  circumstances — and  the  appearance  is  a  frequent  one — 
the  surface  of  the  nerve  is  covered  by  a  semitransparent  or  edematous 
layer,  is  unduly  injected,  and  its  margins,  especially  the  nasal  ones,  are 
veiled  by  striations  composed  of  fine  grayish  lines  and  minute  capil- 
laries ordinarily  not  visible.  The  perivascular  lymph-sheaths  at  the 
same  time  are  unduly  prominent  in  the  form  of  white  lines  along  the 
central  vessels,  especially  the  veins.  This  appearance  has  received  the 
name  "hyperopic  disk,"  and  has  also  been  called  "  spurious  optic 
neuritis"  (Spicer)  and  "pseudoneuritis"  (Stephenson).  Some  cases  of 
pseudoneuritis  are  congenital  in  origin.     (See  Fig.  229.) 

Causes. — (a)  Refractive  error,  especially  hj-peropia  and  h3'peropic 
astigmatism.  (6)  Prolonged  exposure  to  glare  and  heat,  (c)  Certain 
toxic  agents  presently  to  be  described,  and  inflammation  of  the  iris, 
usualh^  of  the  syphilitic  t^-pe.  (d)  Certain  disorders  of  the  brain,  espe- 
cially various  types  of  chronic  insanity.  Focal  brain  lesion — for  ex- 
ample, cerebral  embolism — may  be  associated  with  hyperemia  of  the 
nerve-head.  Pathologic  disk-hypcremia  at  one  time  reported  as  fre- 
quent in  the  second  stages  of  syphilis,  while  it  undoubtedly  occurs 
and  may  yield  though  stubbornly  to  antiluetic  treatment,  is  much  less 
frequent  than  the  earlier  records  indicate.  The  difference  between  a 
hyperemia  and  a  beginning  neuritis  might  well  be  difficult  to  determine. 
Treatment. — This  depends  entirely  upon  the  cause.  Refractive 
error  should  be  corrected  if  this  is  the  apparent  origin  of  the  trouble. 
Constitutional  measures  will  be  required  if  there  is  reason  to  beheve 
that  some  general  cause  is  at  work. 

Anemia  of  the  Nerve=head. — This  is  not  a  disease  peculiar  to 
the  optic  nerve,  but,  like  retinal  anemia,  occurs  as  part  of  a  general 
anemia,  or  because  of  obstruction  to  the  central  vessels — for  example 
in  embolism. 

It  is  often  most  dillicult  to  interpret  the  significance  of  pallor  of  the 
papilla.  Usually  it  will  require  more  than  mere  inspection  to  decide 
whethei-  or  not  a  pallid  disk  is  pathologic. 

1.  Intra-ocular  Optic  Nerve  Inflammation  and  Edema. — 
For  convenience  these  conditions  may  be  described  as  {a)  iittra-ocukir 
optic  neuritis,  or  peripheral  optic  neuritis,  and  (6)  tngorgimcnt-cdiina 
of  the  papilla,  or  choked  disk. 

If  the  lesions  consist  of  a  hyi)ereniia  and  a  moderatt*  s\<-eIliMg  of  tiie 
nerve-head  anil  no  unusual  overfilling  of  the  veins,  and  of  an  exudation 
which  produces  discoloration  and  opacity  of  the  jnipilla,  so  that  its 
margins  and  surface  are  obscured  or  hidden,  and  the  whole  process  is 
not  strictly  limited  to  the  disk,  but  passes  into  the  retina  immediately 


Plate  VL 


The  fundus  of  the  right  eye  of  a  patient  with  tumor  of  the  brain, 
showing  choked  disc. 


INTRA-OCULAR   OPTIC   NERVE    INFLAMMATION   AND   EDEMA     519 

surrounding  it,  descending  neuritis  is  often  employed  as  a  descriptive 
term. 

If  the  lesions  are  chiefly  confined  to  the  nerve-head  itself,  and  there 
are  great  swelling  and  engorgement,  suggesting  mechanical  compres- 
sion, marked  distention  of  the  retinal  veins,  and  hemorrhages  in  and 
near  the  edematous  papilla,  the  term  choked  disk,  or  papilledema 
(Elschnig,  Parsons)  is  used  to  describe  the  condition. 

If  the  retina  is  extensively  involved,  with  hemorrhages  along  the 
vessels,  spots  of  degeneration,  sometimes  collected  in  a  star-shaped 
figure  analogous  to  that  seen  in  renal  retinitis,  the  term  neuroretinitis 
is  frequently  utilized. 


Fig.  230. — Ophthalmoscopic  picture  of  papillitis  and  semidiagrammatic  representation 
of  a  longitudinal  section  of  the  nerve-head. 


To  avoid  this  confusion  of  names,  Leber  proposed  the  general  term 
papillitis,  and  if  it  is  understood  to  refer  only  to  those  types  evidently 
of  inflammatory  origin,  the  word  is  suitable. 

Symptoms. — In  general  terms,  the  symptoms  which  follow  belong 
to  the  conditions  now  under  consideration,  but  vary  in  their  intensity  or 
elaboration  chiefly  in  so  far  as  the  swelling  of  the  papilla  is  concerned, 
according  as  neuritis  (optic  neuritis)  or  engorgement-edema  (choked 
disk,  papilledema)  is  present. 

1.  Changes  in  the  Nerve-head. — (a)  There  are  increased  redness  of 
the  disk  and  obscuration  of  its  borders,  followed  by  swelling  of  the 


520  DISEASES    OF   THE    OPTIC    NERVE 

papilla,  loss  of  the  light-spot,  and  complete  hiding  of  the  margins,  the 
center  usually  remaining  more  red  than  the  periphery,  which  has  a 
grayish  tint  and  shades  gradually  into  the  surrounding  retina.  The 
swelling  may  increase,  assume  a  mound  shape  of  mixed  grayish  color, 
and  finally  the  form  of  the  disk  is  lost,  and  its  position  can  be  inferred 
onlj'^  by  the  convergence  of  the  vessels.  The  height  of  this  swelling  is 
measurable  by  the  table  given  on  page  113  and  by  the  parallactic  test. 
White  spots  and  patches  are  often  seen  in  the  elevation  sometimes 
covering  the  retinal  vessel. 

2.  Changes  in  the  Vessels. — The  arteries,  smaller  than  normal,  pur- 
sue a  moderately  straight  course  and  are  difficult  of  recognition,  being 
partly  concealed  by  the  swelling.  Occasionally  spontaneous  pulsation 
is  visible.  The  veins  are  dark  in  color,  distended  and  tortuous,  and 
pass  along  the  slope  of  the  elevation,  often  dipping  into  the  infiltrated 
tissue.  The  light-streak  is  not  lost,  at  least  not  where  the  vessel  is 
clearly  visible.  The  tortuosity  of  the  vessels  is  sometimes  remarkable, 
and  has  been  compared  to  the  writhing  snakes  in  the  Medusa-head. 
The  point  of  emergence  and  convergence  of  the  vessels  may  be  hidden 
by  th(^  infiltration,  so  that  the  center  of  the  swelling  seems  somewhat 
destitute  of  vessels.  In  some  instances  thickening  of  the  adventitia 
of  the  vessels  gives  rise  to  the  appearance  of  white  lines  along  their 
sides. 

3.  Hemorrhages. — In  many  cases  hemorrhages  are  fountl  upon  the 
swollen  papilla  or  in  its  immediate  neighbor hootl.  They  are  in  the 
form  of  narrow,  flame-shaped  extravasations  if  they  lie  in  the  fiber- 
layer,  but  may  also  assume  other  shapes  if  situated  in  a  deeper  plane. 
The  numljer  varies  from  a  single  hemoirhage  to  so  many  that  the 
swollen  nerve-head  assumes  a  hetnorrhagic  form,  or  the  surrounding 
retina  may  be  freely  occupied  by  elongated  or  other  shaped  patches  of 
blood.  Usually  optic  neuritis  and  choked  disk  are  bilateral,  although 
it  is  not  uncommon  to  find  the  process  more  advanced  in  one  eye  than 
the  other.  Occasionally  the  condition  is  confined  to  one  ey(>  and'tlie 
other  remains  unaffected. 

In  addition  to  the  ophthalmoscopic  changes  just  detailed,  the  fol- 
lowing points  deserve  notice: 

1.  Vision  in  optic  neuritis  and  in  choked  disk  may  be  defective  or 
it  may  be  entirely  unaffected;  hence  the  mere  presence  of  good  central 
sight  should  never  be  considered  cause  to  omit  ophthalmoscopic  ex- 
amination. Usually  the  vision  of  one  eye  is  more  affected  than  its 
fellow.  Impairment  of  sight  may  come  on  rapidly  or  slowly.  Oi-ca- 
sionally  vision  is  lost  with  gi'cat  suddeimess,  but  this  is  rare.  Photo- 
metric examination  will  usiiall>'  reveal  disluibance  of  the  light-stnsr 
(.see  i)age  07). 

2.  Tho  field  of  vision  presents  foi-  consideration  its  periplierv,  which 
may  at  first  i)e  unaffected  and  latei-  show  iiregular  and  concentric 
contraction;  an  increase  in  the  size  of  tiu'  normal  l)lind-spot,  which 
becomes  correspondingly  gre.it  in  coniiJarison  with  the  amount  of 
swelling;  the  form.ation  of  an  almornial  blind-spot   oi-  scotoma  due  to 


INTRA-OCULAR    OPTIC    NERVE    INFLAMMATION    AND    EDEMA     521 

involvement  of  the  axial  fibers  and  occasionally  simulating  the  Bjerrum 
t}' pe  (V.  Szily) ;  the  absence  of  half  of  the  visual  field  (hemianopsia) 
if  the  intracranial  mischief  which  may  have  been  the  cause  of  the 
neuritis  or  choked  disk  is  so  situated  as  to  produce  this  phenome- 
non; and  finally,  defective  color-perception,  which  may  exist  when 
there  is  no  change  in  central  vision  and  no  limitation  of  the  form-field. 
Gushing  and  Bordley  have  described  reversal  of  the  color  lines  as  it 
occurs  in  hysteria  in  association  with  increased  intracranial  tension, 
with  and  without  choked  disk,  as  well  as  blue-blind  areas,  which  disap- 
peared after  the  restoration  of  intracranial  tension  to  normal  by  opera- 
tion. Although  reversal  of  the  color  lines  in  these  circumstances 
is  demonstrable,  it  must  not  be  regarded  as  a  safe  indication  of  the 
existence  of  increased  intracranial  tension. 

3.  External  Appearances. — There  are  no  changes  in  the  exterior 
of  the  eye  indicative  of  swelling  or  inflammation  in  the  nerve-head. 
There  are  no  characteristic  pupillary  phenomena.  The  pupil  may  be 
moderately  dilated,  but,  as  Kampherstein  has  shown,  in  the  majority 
of  cases  of  choked  disk  its  reaction  is  normal.  If  blindness  is  complete, 
the  iris  usually  is  immobile.  Normal  reaction,  however,  has  been 
noted  even  in  the  presence  of  complete  blindness  (Kampherstein). 
(See  also  page  64). 

Diagnosis. — The  diagnosis  of  optic  neuritis  and  of  choked  disk  de- 
pends upon  a  direct  ophthalmoscopic  examination  of  the  inflamed  or 
edematous  disk.  The  method  of  determining  the  height  of  the  eleva- 
tion has  been  explained. 

The  student  should  not  mistake  the  slightly  prominent  disks  that 
are  occasionally  seen  in  hj^peropia  for  beginning  papillitis  or  papil- 
ledema. There  may  be  a  superficial  neuritis  in  hyperopia,  and  in  these 
circumstances  it  is  difficult  at  times  to  decide  whether  the  disk  has 
become  edematous  or  inflamed  under  the  influence  of  an  intracranial  or 
general  disease,  or  whether  it  is  congested  as  the  result  of  eye-strain. 
If  the  condition  is  due  to  intracranial  disease  the  disk  edges  are  more 
blurred  than  in  pseudoneuritis,  the  physiologic  pit  is  contracted  or 
filled  in,  the  veins  are  darker  and  usually  more  tortuous,  and  a  careful 
examination  of  the  size  and  shape  of  the  blind-spot,  of  the  light-sense, 
and  of  the  visual  field  should,  in  most  instances,  establish  the  diagnosis. 
The  average  swelling  of  papilledema  in  cerebral  tumors  is,  according  to 
the  author's  and  Holloway's  measurement,  4.57  D.  It  varies  from  3 
to  9  or  10  D.  Particularly^  satisfactory  studies  of  the  various  stages  and 
types  of  choked  disk  and  papillitis  can  be  made  with  the  Gullstrand 
ophthalmoscope  (page  96). 

The  course  of  the  choked  disk  is  a  variable  one.  Occasionally  swelling 
of  the  intra-ocular  end  of  the  nerve  will  come  on  with  great  rapidity; 
in  other  instances  it  is  slow  in  its  course  and  lasts  for  months  and  even 
years,  with  progressive  failure  of  vision.  While  in  a  certain  sense  the 
various  stages  into  which  systematic  writers  have  divided  choked  disk 
(papilledema)  and  optic  neuritis  are  artificial,  they  are  convenient  for 
descriptive  purposes.     The  following,  referring  especially  to  choked 


522  DISEASES    OF    THE    OPTIC    NERVE 

disk,  are  those,  somewhat  modified,  which  wore  recorded  by  Marcus 
Gunn: 

1.  Increased  redness  of  the  disk,  with  blurring  of  its  upper  and 
lower  margins,  with  a  gradual  progrc:>sion  of  the  blurring  to  the  nasal 
edges,  while  the  temporal  margin  is  still  visible,  represents  the  first 
stage. 

2.  Increased  edema  of  the  nerve-head,  beginning  filling  in  of  the 
physiologic  pit,  involvement  of  the  temporal  margin  of  the  disk,  with  a 
tendency  of  the  edema  to  spread  into  the  surrounding  retinal  area,  and 
uneven  distention  and  darkening  of  the  retinal  veins  represent  the 
second  stage. 

3.  Decided  increase  of  edema,  elevation  and  size  of  the  nerve-head, 
with  vascular  striation  of  the  swollen  tissue  and  striae  of  edema  in  the 
form  of  lines  in  the  swollen  retina  between  the  disk  and  macula,  marked 
distention  of  the  retinal  veins  and  retinal  hemorrhages  represent  the 
third  stage. 

4.  Increase  in  the  prominence  of  the  disk,  which  assumes  a  mound 
shape  and  begins  to  lose  its  reddish  color  and  juicy  appearance  and  to 
become  opaque,  exudation  in  and  on  the  swollen  disk  and  surrounding 
retina,  elaboration  of  the  retinal  hemorrhages  in  size  and  number 
represent  the  fourth  stage. 

0.  Decided  subsidence  of  the  vascularity  of  the  papilledema  and 
increasing  pallor,  with  or  without  sinking  of  its  prominence,  apparently 
contraction  of  the  retinal  arteries  and  thickening  of  their  perivascular 
lymph-sheaths,  spots  of  degeneration  in  the  retina,  especially  in  the 
macula,  represent  the  fifth  stage,  which  passes  into  the  final  stage  of 
so-called  papillitic  atrophy. 

As  the  last  stage  is  ushered  in  the  borders  of  the  disk  begin  to  be 
visible,  usually  first  upon  the  temporal  side,  until  finally  all  margins 
again  are  apparent,  at  first  a  little  mellowed,  while  the  center  is  still 
covered  by  the  remnant  of  the  inflammatory  tissue.  Finally,  the  edges 
of  the  disk  are  clear,  its  color  is  white  and  atrophic,  and  its  center  be- 
comes apparent.  Both  sets  of  vessels  are  contracted,  and  may  be 
streaked  along  their  sides  with  whitish  tissue.  Areas  of  retinochoroid- 
itis  and  elevated  patches  of  degeneration,  marking  spots  of  former 
hemorrhages,  are  often  apparent.  Second  attacks  of  neuritis  and 
choking  of  the  disk  may  occur,  as  in  a  case  observed  by  the  author  and 
A.  G.  Thomson.  A  choked  disk  may  be  inii)lanted  on  an  atroi)hic 
nerve-head. 

In  addition  to  the  swelling  of  the  disk,  there  may  be  marked  tdctna 
of  the  retina  and  lines  of  edema  in  the  macular  region,  forming  the  so- 
called  macular  Jldurc,  or  inacular  Jan  (Paton),  not  unlike  the  appearance 
which  is  so  striking  in  certain  types  of  renal  retinitis  (see  page  473). 
It  occurs  in  a  fair  percentage  of  cases  of  cerebral  and  cerebellar  tumors 
(fully  15  per  cent,  according  to  Paton's  figures),  and  may  reach  a 
height  ('(jual  to  or  greater  than  tluit  of  the  choked  disk.  In  addition  to 
these  areas  of  retinal  cdciiia,  tlwre  may  dcvcloi)  in  th(>  inacuhir  region 
yellowish-white  and  degeneration  spots,  intermi.xed  with  hniiorrhages. 


INTRA-OCULAR    OPTIC    NERVE    INFLAMMATION    AND    EDEMA     523 

The  prognosis  of  optic  neuritis  and  choked  disk  depends  upon  the 
cause  and  the  duration  of  the  process.  If,  for  example,  syphiHs  is  the 
active  agent,  there  is  reason  to  hope  that  suitable  treatment  will  be  fol- 
lowed by  good  results.  If  the  focus  of  disease,  for  instance,  in  the  ac- 
cessory sinuses,  can  be  removed,  vision  may  be  saved  and  edema  and 
inflammation  will  subside.  If  the  papilledema  depends  upon  increased 
intracranial  tension,  and  this  is  relieved  by  decompressive  trephining, 
or  by  a  radical  operation  with  removal  of  the  growth,  and  the  disk 
changes  have  not  passed  beyond  the  third  stage,  the  prognosis  as  to 
sight  is  favorable.  Untreated  choked  disk,  or  optic  neuritis,  almost 
always  produces  blindness ;  very  exceptionally  the  original  disease  con- 
tinues, but  the  neuritis  subsides  (Oppenheim). 

Causes. — The  most  frequent  cause  of  choked  disk  is  tumor  of  the 
brain,  inasmuch  as  it  occurs  in  fully  80  per  cent,  of  the  cases.  Usually 
the  intracranial  neoplasm  must  have  existed  for  some  time  and  the 
increased  intracranial  tension  has  lasted  for  a  definite  period  before 
the  engorgement-edema  develops.  The  period  from  the  beginning  of 
choked  disk  to  the  height  of  its  swelling  in  some  instances  comprises 
only  a  few  weeks;  in  others,  months  and  even  years  may  elapse  before 
the  disk-edema  appears.  It  is  not  possible  to  determine  with  certainty 
from  the  stage  of  the  disk  or  retinal  phenomena  what  the  duration  of 
the  cerebral  lesion  is,  but  if  choked  disks  arise  with  suddenness  and  the 
edema  rapidly  increases,  thej^  indicate  an  increase  in  intracranial  pres- 
sure, either  because  the  growth  itself  has  gained  in  volume  or  because 
hemorrhage  has  occurred  in  or  around  it. 

Tumors  of  the  corpora  quadrigemina  give  the  highest  percentage 
of  choked  disk,  and  next  tumors  of  the  parieto-occipital  region  and  of 
the  cerebellum,  which  yield  an  almost  identical  percentage  (tables  of 
John  E.  Weeks  and  J.  M.  Martin).  Tumors  of  the  basal  gangha  are 
usually  associated  with  papilledema.  Choked  disk,  if  it  does  not  fail 
entirely  as  a  symptom  of  tumor  of  the  pons,  of  the  medulla,  and  of  the 
corpus  callosum,  is  apt  to  be  late  in  its  development,  and,  to  a  certain 
extent,  this  lateness  of  development  applies  to  tumors  of  the  frontal  and 
parietal  convolutions.  It  is  probable  that  pontine  tumors  give  rise  to 
choked  disk  only  if  they  also  involve  some  neighboring  structure,  and, 
according  to  Paton's  researches,  the  bulk  of  cases  of  brain  tumor  with- 
out choked  disk  are  those  of  pontine  and  subcortical  origin,  but  if  the 
subcortical  growths  spread  to  the  base,  the  disk  changes  appear. 
Tumors  of  the  cerebellum  are  prone  to  cause  a  more  intense  form  of 
choked  disk,  with  rapid  depreciation  of  vision,  than  cerebral  neoplasms, 
and  the  same  intensity  of  the  process  is,  according  to  some  authors, 
evident  in  morbid  growths  of  the  midbrain  and  thalamus,  while  it  is 
less  pronounced  in  subcortical,  parietal,  and  frontal  lobe  tumors. 
Whether  the  refraction  of  the  eye  has  any  influence  on  the  develop- 
ment of  choked  disk  is  undecided.  That  myopia  seems  to  have  a 
deterrent  effect  has  been  asserted  (Marcus  Gunn,  the  author);  its 
influence  in  this  respect  is  doubted  by  other  observers  (Paton,  Parsons, 
Bordley  and  Gushing).     The  development  of  choked  disk  does   not 


524  DISEASES    OF    THH    OPTIC    NKHVE 

nocpssarily  dopond  upon  the  size,  j^ituation,  or  stnu-tiiro  of  the  intra- 
cranial neoplasm,  and  all  types  of  morbid  growths  may  originate 
papilledema — fibroma,  sarcoma,  glioma,  carcinoma,  solitary  tubercle, 
aiul  gUMuna. 

It  also  api^ears  with  echinococcus  cysts,  epidural  and  subdural  clots, 
intracianial  trauma,  abscess  of  the  brain,  and  middle-ear  disease, 
when  this  has  extended  to  the  cerebrum.  Von  Hippel  describes  a 
form  of  optic  neuritis  with  affections  of  the  ear  which  may  exist  with- 
out disturbing  sight  and  remain  even  after  operation  has  removed  its 
ai)par('nt  cause.  (See  also  page  52G.)  Acute  blitidnes.s  with  normal 
fundus  due  to  the  pressure  of  internal  hydiocephalus  caused  by  l)rain 
abscess  has  been  described  (Pagenstechcr). 

Injuries  to  the  skull  (blows,  fractures,  etc.)  may  be  followed  by  rapid 
disk-edema  (beginning  choked  disk)  and  in  all  such  cases  repeated 
ophthalmoscopic  examinations  are  required.  During  the  past  war 
a  large  opportunity  arose  for  demonstrating  the  value  of  such  examina- 
tions no  matter,  as  Greenwood  has  said,  whether  the  cranial  injuries  were 
simple  concussions,  furrow  wounds,  fractures  or  penetrating  wounds. 
Finding  disk  changes  and  noting  their  character  (choked  disk  or 
papillitis)  often  furnished  the  indication  for  operation.  Almost 
always  swelling  of  the  papilla  appearing  soon  after  a  cranial  injury 
indicates  a  developing  choked  disk.  Disk-changes  at  a  later  period 
may  fully  develop  into  papilledema  (choked  disk)  and  be  due,  for  ex- 
ample, to  a  cyst,  or  papillitis  (optic  neuritis)  may  be  dei^enilent  on  a 
meningitis  or  brain  abscess.  Bilateral  choked  disks  arising  weeks  or 
months  after  cranial  injury  are  of  grave  import  in  that  they  indicate 
a  serious  intracianial  lesion  which  has  escaped  notice. 

Of  the  four  varieties  of  meningitis — simple,  tuberculous,  traumatic 
and  cerebrospinal — tuberculous  disease  of  the  brain  is  the  most  fre- 
quent cause  of  optic  neuritis,  the  percentage  varying  from  70  to  81  per 
cent.  The  appearances  of  the  disk  most  often  are  those  which  have 
l)een  described  in  connection  with  (le.sccnding  neuritis  (see  page  510). 
When  there  is  direct  pressure  upon  the  tracts  and  chiasm,  the  swollen 
papilla  has  a  peculiar  grayish-white  color,  without  nuich  vascularity, 
and  a  similar  app(>arance  is  sometimes  caused  by  tumors  of  the  c(M-e- 
bellum.  In  epidemic  cerei)rospinal  meningitis  optic  neuritis,  tliat  is, 
a  descending  neuiitis,  or  choked  disk  fi'om  distention  of  tlu'  third 
ventricle,  may  develop.  These  optic  nerve  changes  are  not  fre(|ueiit 
according  to  Uhthott"  (17  pci-  cent.).  Tlie  author's  expcM-ience.  ("spe- 
cially (hiring  the  war,  would  indicate  a  higher  percentage.  Hotli 
choked  disk  and  optic  neuiitis  occur  with  otitic  meningitis. 

Other  intiacranial  causes  are  softening  of  the  brain,  luMuorrhagic 
j)achyineningitis,  cerebrilis,  heniorrh;ige,  thrombosis  oftlu*  cavernous 
simis,  hydrocephalus,  aneurysm,  and  disorders  of  the  piluilai>-  body 
and  exlrasellar  growths. 

( 'hoked  (hsk  is  comiiion  in  cci('l)ral  sxphilis,  which,  next  after 
tumor,  is  its  most  fre([n('nt  cause  (IhtholT).  The  cei-ebra!  manifesta- 
tions in  this  regai'd   have   been   classilied   by    tiiis  author  as   follows: 


IXTRA-OCULAR    OPTIC    NERVE    INFLAMMATION    AND    EDEMA     525 

Gumma  of  the  brain  and  its  membranes;  gummatous  basilar  menin- 
gitis; syphilitic  lesions  of  the  cerebral  vessels  and  their  sequels; 
internal  hydrocephalus  of  syphilitic  origin.  These  lesions  afford  the 
conditions  necessary  for  elevating  the  intracranial  pressure.  Igers- 
heimer  states  that  a  typical  choked  disk  maj^  probably  develop  in 
association  with  cerebral  lues,  even  though  anatomical  demonstration 
is  lacking. 

Occasionalh'  general  paresis,  epilepsy,  and  disseminated  sclerosis 
are  accompanied  by  optic  neuritis  and  by  choked  disk.  Papillitis  may 
precede,  accompany,  or  follow  mj-elitis  (ophthalmoneuromyelitis). 

In  addition  to  the  intracranial  causes  of  papillitis,  this  phenomenon 
may  arise  from  a  general  infection.  To  this  form  Uhthoff  gives  the 
name  infectious  optic  neuritis.  According  to  this  observer,  it  should  be 
differentiated  from  those  cases  which  are  caused  by  orbital,  intra- 
ocular, or  intracranial  lesions,  and  may  be  caused  bj'  any  of  the 
following  diseases  placed  in  order  of  their  frequency:  Influenza, 
syphilis,  rheumatism,  malaria,  typhus  fever,  measles,  whooping-cough, 
diphtheria,  polyneuritis,  small-pox,  beriberi,  erysipelas,  scarlet  fever, 
tuberculosis,  typhoid  fever,  gonorrhea,  and  relapsing  fever.  The 
neuritis  ma}"  manifest  itself  as  a  papillitis  or  as  a  retrobulbar  neuritiS;, 
and  Uhthoff  thinks  that  the  optic  nerve  conditions  are  most  apt  to 
arise  during  the  stage  of  convalescence  and  are  probably  due  to  the 
action  of  toxins,  and  not  directly  to  the  micro-organisms.  The 
meningitis  which  may  complicate  various  infectious  diseases  may  be 
the  agency  in  the  development  of  papillitis  and  choked  disk.  In 
children  with  congenital  syphilis,  even  when  only  a  few  weeks  old,  optic 
neuritis  is  not  uncommon,  according  to  Mohr.  Optic  neuritis  may 
also  be  caused  by  toxic  agents,  for  example,  by  lead,  atoxyl,  Filix  mas, 
and  alcohol,  bj'  anemia,  both  when  this  is  an  essential  process  and  when 
it  is  caused  by  excessive  hemorrhage,  by  disturbances  of  menstruation, 
by  lactation,  by  exposure  to  cold,  by  myxedema,  by  sunstroke,  and 
by  injuries.  An  association  of  chlorosis,  choked  disk,  and  abducens 
palsy  has  been  observed,  attributed  by  ]\Ieller  to  thrombosis  in  the 
region  of  the  cavernous  sinus.  Marked  disk-edema  (choked  disk) 
may  complicate  chlorotic  anemia. 

Metastatic  optic  neuritis  has  been  recorded  as  occurring  in  sepsis 
(Axenfeld,  von  Michel).  Optic  neuritis  may  be  associated  with 
diseases  and  injuries  of  the  anterior  part  of  the  eye.  Under  these  con- 
ditions vitreous  opacities  may  also  be  present. 

Optic  neuritis  followed  by  atroph}^  may  arise  in  association  with 
deformities  of  the  skull,  and,  according  to  Friedenwald's  analysis, 
the  patients  for  the  most  part  have  had  oxycephalic  or  steeple-shaped 
skulls  ("tower  skulls").  Blindness  without  changes  in  the  intra- 
ocular end  of  the  optic  nerve  due  to  cranial  deformity  was  reported  by 
C.  A.  Oliver.  Papillitis  occasionally  occurs  as  a  congenital  affection 
in  several  members  of  the  same  family  and  sometimes  appears  without 
evident  cause. 

Choked  disk  and  optic  neuritis  may  depend  upon  disease  of  the 


526  DISEASES  OF  THE  OPTIC  NERVE 

orbital  region — inflammation  of  its  contained  tissues,  tumors,  caries, 
and  periostitis,  especially  around  the  optic  foramen,  upon  purulent 
disease  of  the  antrum  of  Highmore  and  the  frontal  sinus,  and  morbid 
processes  of  the  upper  posterior  portion  of  the  nose  and  of  the  sphe- 
noid and  ethmoid  bone  (sinusitis).  In  most  of  these  instances,  unless 
both  orbits  or  the  sinuses  are  affected,  the  papillitis  is  unilateral,  and 
there  are  other  sj^mptoms  around  the  eye  which  point  to  the  local 
condition.  Optic  neuritis  may  be  due  to  dental  disease  and  to  other 
focal  infections,  for  instance  in  the  tonsils.  The  relation  of  focal  in- 
fections in  the  teeth  and  tonsils  and  of  paranasal  sinus  disease  to  papil- 
litis is  an  important  one  to  which  much  attention  has  been  directed  in 


f 


r 


Fig.  231. — Fundus  of  the  right  eye  of  a  patient  with  tumor  of  the  brain  and  choked 
disk;  swelling  6  D.     (Service  of  Dr.  Edward  Martin  in  Universitj'  Hospital.) 

recent  years.  Purulent  iniddlc-t^ar  disease  and  mastoid  infection  by 
virtue  of  intracranial  comi)licati()n.s  may  be  accompanied  by  jiajiillitis; 
should  this  arise  the  indication  for  oi)eration  is  evident.  Optic  neuritis 
with  cavernous  sinus  thrombosis  is  elsewhere  discussed  (page  635). 

A  rare  foiin  of  optic,  neiu'itis  is  that  descrilxnl  in  association  with 
persist (!nt  ih-opping  of  a  watery  fluid  from  the  nose.  Ileadaclie,  vomit- 
ing, unconsciousness,  and  delirium  are  present.  The  lUiid  ha.s  l>een 
believed  to  be  identical  with  the  c(>rebrospinal  lUiid  (Leber),  or  to  be 
due  to  nasal  disease  in  the  form  of  small  polypi  [Nettleship  and  Priest- 
ley Smith].  Tnl('iii;il  liydi'occpjialus  was  prcsiMit  in  some  of  the 
l)ati('n1s. 

Treatment.  This  depends  upon  the  cause  of  th(»  condition,  in  all 
syphililir  cases  rapid  nK^rcuriali/ation  should  l)e  tried,  followeil  later 
by   tile    iodids.     Salvarsan   and    neosalvarsan    iiave   l)een   efTectivoly 


INTRA-OCULAR    OPTIC    NERVE    INFLAMMATION    AND    EDEMA     527 

employed.     Orbital  and  sinus  diseases  and  focal  infections  indicate 
appropriate  surgical  measures. 

Since  Sir  Victor  Horsley's  announcement,  more  than  thirty  years  ago, 
that  the  release  of  intracranial  tension  arrests  and  cures  optic  neuritis 
(choked  disk),  numerous  operations  have  been  performed,  with  sat- 
isfactory results.  In  a  certain  number  of  cases  of  brain  tumor  the 
growth  can  be  removed  by  a  radical  operation,  but  even  if  it  is 
inoperable,  as  it  frequent!}^  is,  or  cannot  be  localized,  a  palliative  opera- 
tion, that  is,  cerebral  decompression,  should  be  performed  in  order  to 
save  sight,  and  the  earlier  it  is  done,  the  better  the  results  will  be — i.  e., 
operation  should  be  undertaken  before  the  third  stage  of  the  disk 


V  /^ 


4f 


Fig.  232. — Fundus  of  the  right  eye  of  the  same  patient  shown  in  Fig.  231  one  month 
after  cerebral  decompression. 

change  is  reached.  Usually,  after  technically  correct  operations  (and 
in  all  pretentorial  tumors  temporal  decompression  is  the  operation  of 
choice,  and  in  all  subtentorial  lesions  a  suboccipital  decompression  is 
indicated  [C.  H.  Frazier]),  the  choked  disk  begins  to  subside  from  the 
third  to  the  tenth  daj^  and  the  subsidence  is  complete  at  the  end  of 
six  weeks.  The  same  operation  is  urged  by  Gushing  in  choked  disk 
caused  by  cerebral  edema,  infections,  and  intracranial  hemorrhage. 
Choked  disk  has  also  been  advantageously  treated  by  lumbar  punc- 
ture, and  W.;G.  Spiller  and  the  author  have  pubhshed  some  very  suc- 
cessful results  secured  with  the  help  of  this  procedure;  only  a  small 
quantity  of  fluid  (.5  c.c.)  should  be  withdrawn  at  a  time.  This  caution 
lessens  the  danger  of  lumbar  puncture  in  the  presence  of  brain  tumor. 
Puncture  of  the  corpus  callosum  and  drainage  of  the  ventricle  have  been 
utihzed  to  reduce  intracranial  pressure  and  thus  relieve  papilledema. 


528  DISEASES    OF    THE    OPTIC    NERVE 

Significance  of  Choked  Disk. —  Doul)le  chokcnl  disk  is  hijjhly  sig- 
nificant of  intiacianial  disease,  especially  tumor  or  basilar  meninfiitis. 
Indeed,  it  is  the  most  important  general  symptom  (jf  this  condition.  l)ut 
it  is  not  a  pathognomonic  sign.  The  other  causes  of  optic  neuritis  and 
choked  disk  which  have  been  mentioned  must  be  excluded,  and  care 
must  be  taken  not  to  mistake  the  macular  figure  (see  page  522)  for  an 
albuminuric  retinitis.  Although  the  presence  of  choked  disk  is  so 
highly  significant  of  cerebral  tumor,  of  itself  it  possesses  no  tlistinct 
localizing  importance.  Usually  papilledema  is  bilateral,  Init  in  a  cer- 
tain number  of  instances  it  is  unilateral,  and  frequently  there  is  an 
excess  of  choking  in  one  eye  as  compared  with  the  other.  Whether 
this  is  a  sure  indication  that  the  tumor  is  on  the  same  side  as  the  choked 
disk  or  the  excess  of  edema  is  vmdecided.  Horsley  l)elieved  that  choked 
disk  tends  to  develop  earlier  and  to  be  more  marked  in  the  eye  corre- 
sponding to  the  side  on  which  the  tumor  grows,  but  Paton  doubts  if 
reliance  can  be  placed  on  this  sign.  In  the  author's  and  Holloway's 
investigations  in  the  majority  of  cases  the  greater  swelling  was  on  the 
same  side  as  the  tumor;  but  there  were  many  cases  in  which  this  rule 
did  not  hold  good.  The  development  of  choked  disk  does  not  depend 
upon  the  size  nor  on  the  type  of  the  tumor,  although  according  to 
some  authorities  disk  changes  are  most  frequently  absent  in  tubercu- 
lous growths  and  most  frequently  present  with  sarcoma,  glioma,  ami 
cysts.  According  to  Walter  R.  Parker,  choked  disk  caused  by  in- 
creased intracranial  tension  appears  first  in  the  eye  with  the  lesser 
intra-ocular  tension,  as  measured  with  the  Schiotz  tonometer.  As  this 
author  himself  points  out,  th's  observation  recjuires  confirmation. 
The  distinction  between  papillitis  and  choked  disk  obviously  cannot 
entirely  be  made  according  to  the  degree  of  swelling  which  is  jiresent 
(2  D  or  moi-e  characterizing  choked  disk  [Uiithot^"]). 

Pathogenesis  of  Papillitis  and  Choked  Disk. — As  is  well  known, 
von  Graefe  at  one  time  sharply  distinguished  Ix'tween  (hsccntliiKj 
neuritis  and  choked  disk  {Stdttutnjs-jxipiUc). 

If,  for  example,  in  meningitis  the  sheaths  of  the  optic  nerve,  which 
are  continued  over  it  as  prolongations  of  the  corresponding  brain- 
memljranes,  participate  in  tlu'  infiannnation,  as  th(\v  undoul)tedly 
may,  there  is  at  first,  as  (JreetT  points  out,  a  iHrincitrids,  which  extends 
by  way  of  the  connective-tissue  septa  to  the  trunk  of  the  neive.  The 
evidences  of  this  inflammation,  soon  visil)le  to  the  o|)hthalmoscope, 
present  the  apjiearances  of  a  moderate,  that  is,  not  engorged,  intra- 
ocular optic  neuritis,  and  the  whole  i)roce.*<s  is  a  dcsccndltui  neuritis. 

11,  on  t  he  ot  her  hand,  the  slate  of  the  neive-head  indicates  engoige- 
inent,  edema,  and  mechanical  obstruction,  and  the  evidences  of  these 
conditions  are  visil)le  to  the  o|)lit  halinoscope  in  t  lie  appe;irances  already 
described  (see  page  522),  the  process  is  a  chokid  disk  or  inipHUdt  nui. 

Inasnuich  as  o|)ht  halmo,scopic;illy  it  is  frecpiently  diflicult  to  dis- 
tinguish a  neuritis  from  a  beginning  choked  disk,  and  as  the  I'onditions 
may  be  mixed,  llughlings  .l.-ickson  expressed  the  opinion  th;it  there  is 
one  kind  ol  opt  ic  neuritis  from  inl  racr.'inial  discMse  which  may  m:inif(>.st 


INTRA-OCULAR    OPTIC    NERVE    INFLAMMATION    AND    EDEMA     529 

itself  under  different  appearances,  sometimes  with  and  sometimes  with- 
out "swelHng  of  the  disk."  It  would  seem,  however,  that  it  is  still 
proper  to  maintain,  within  the  limits  described,  the  distinction  to  which 
reference  has  been  made. 

Numerous  theories  have  been  propounded  to  explain  the  patho- 
genesis of  choked  disk.  Von  Graefe  believed  that  choked  disk  was  due 
to  a  venous  stasis  occasioned  by  obstruction  to  the  return  of  venous 
blood  from  the  cavernous  sinus.  This  theory  ceased  to  be  tenable 
when  Sesemann  demonstrated  the  anastomosis  between  the  ophthal- 
mic and  the  anterior  facial  veins  Parinaud  taught  that  choked  disk 
is  due  to  extension  of  the  interstitial  edema  of  the  brain  tissue  through 
the  optic  nerve  to  its  intra-ocular  end,  a  theory  to  which  Sourdille 
subscribes;  and  Kampherstein  believes  that  often  it  can  be  explained 
only  by  a  preceding  edema  of  the  brain,  extending  through  the  optic 
nerve  to  the  lamina  cribrosa  and  thus  causing  choking  of  the  nerve- 
head. 

The  inflammatory  or  toxin  theory,  with  various  modifications,  as- 
sumes, as  Leber  suggested  and  Deutschmann  afterward  endeavored 
experimental!}^  to  show,  that  so-called  papillitis  is  not  a  product  of 
edema,  but  an  inflammatory  affection,  the  fluid  which  distends  the 
sheath  of  the  nerve  possessing  an  irritative  quality;  or,  in  other  words, 
that  the  subarachnoid  fluid  is  infected  by  products  from  the  intra- 
cranial disease  or  lesion  which  is  the  prime  cause  of  the  trouble. 

The  mechanical  (lymph-space)  theory  of  Schmidt-Rimpler,  ascribed 
to  the  dropsy  of  the  intersheath  space  of  the  optic  nerve,  which  is 
caused  by  the  increased  subarachnoid  fluid  being  forced  into  this  situa- 
tion under  the  influence  of  elevated  intracranial  pressure,  a  mechanical 
or  compressing  action,  or  to  the  fluid  which  found  its  way  into  the 
lymphatic  spaces  of  the  optic  nerve,  an  action  causing  edema,  con- 
gestion, and  later  inflammation. 

Although  in  the  investigation  of  choked  disk  from  the  experimental 
standpoint  the  results  of  various  observers  have  not  always  been  in 
accord,  on  the  whole  it  has  been  demonstrated,  as  W.  R.  Parker  has 
well  shown,  that  by  artificially  increasing  intracranial  pressure  choked 
disk  may  be  produced.  Choked  disk,  according  to  Schieck,  is  due  to 
lymph  stasis,  the  cerebrospinal  fluid  passing  by  way  of  the  perivascular 
lymph-sheaths  of  the  axial  bundle  of  the  optic  nerve  and  along  the  cen- 
tral vessels  into  the  disk.  Paton  and  Gordon  Holmes  believe  that 
their  observations  establish  the  fact  that  papilledema  is  an  edema  of 
the  nerve-head  due  to  two  factors — venous  engorgement  and  lymph 
stasis.  Carl  Behr  maintains  that  choked  disk  follows  passive  lymph 
stasis  brought  about  by  virtue  of  a  compression  of  the  optic  nerve 
because  of  an  interruption  of  its  lymph  passages  which  are  proceeding 
centrally,  and  that  this  takes  place  in  the  event,  for  instance,  that  the 
intracranial  pressure  is  elevated  by  a  tumor. 

In  general  terms  it  is  probable  that  choked  disk  is  produced  by  a 
combination  of  factors.  In  this  combination  increased  intracranial 
tension  or  pressure  is  by  far  most  prominent,  and  the  mechanical 

34 


530  DISEASES    OF   THE    OPTIC    NERVE 

theory  of  its  pathogenesis  affords  the  most  satisfactory  explanation. 
If  other  factors  are  potent,  they  have  not  yet  been  definitely  dis- 
covered. 

Inflammatory  or  irritative  processes  in  the  optic  nerve  and  its 
sheaths  sometimes  have  an  active  influence,  and  if  the  inflammatory 
condition  predominates,  the  elevation  of  the  disk  is  less  marked  and  the 
procesJs  is  apt  to  extend  to  the  retina,  where  exudations  and  liemor- 
rhages  are  visible;  in  other  words,  the  lesions  warrant  the  descriptive 
term  inflammatory  optic  neuritis. 

Pathologic  Anatomiy. — In  the  early  stage  of  true  choked  disk  the 
edema  is  non-inflammatory  and  no  evidences  of  inflammation  are 
present.  In  later  stages  moderate  inflammatory  infiltration  is  evi- 
dent. There  may  be  blood  extravasations,  swellings  and  varicosities 
of  the  nerve-fibers,  and  slight  cellular  exudation  along  the  thickeneil 
and  dilated  vessels.  In  the  interstitial  form  of  neuritis  the  inflamma- 
tion begins  in  the  sheath  and  septa,  with  the  formation,  in  addition 
to  the  edema,  of  an  exudation  rich  in  cells,  which  subsequently  or- 
ganizes. There  follow  thickening  of  the  interfascicular  septa,  increase 
of  the  nuclei,  and  degeneration  and  atrophy  of  the  nerve-fibers  from 
pressure.  In  some  cases  degeneration  of  the  ganglion  cells  of  the  re- 
tina is  evident,  depending  upon  the  fact  that  an  arterial  branch  sup- 
plying that  particular  area  has  been  occluded.  Such  degenerative 
areas  may  give  rise  to  scotomas  or  sector-like  defects  in  the  visual  field. 
An  ampulliform  dilatation  of  the  optic  nerve  sheath  posterior  to  the 
eyeball  is  found  in  a  certain  number  of  cases,  and  in  addition  to  dis- 
tention of  the  intervaginal  space  there  may  be  an  infiltration  of  small 
cells  in  the  sheath. 

1.  Optic=nerve  Atrophy. — Under  the  general  term  atrophy  of  the 
optic  nerve  are  included  the  various  types  of  degeneration  and  shrinking 
of  the  fibers  of  the  optic  nerve,  usuall}^  described  under  the  subdivisit)ns 
primary,  secondary,  consecutive  {neuritic  or  postpa pillitic) ,  and  retinal  and 
choroiditic  atrophy.    The  last  are  really  forms  of  consecutive  atrophy. 

Symptoms. — Certain  general  symptoms  are  common  to  optic- 
nerve  atrophy,  although  these  are  subject  to  variations  according  to 
the  clinical  types. 

1.  Changes  in  the  Nerve-head. — (a)  Alterations  of  the  Xortnal  Color 
of  the  Disk. — The  color  of  the  disk  varies  from  a  slight  gray  pallor  to  a 
pure  gray,  greenish-gray,  or  entirely  white  ("paper  white'')  hue. 
Many  intermediate  forms  of  discoloration  occur;  tluis  there  may  be  a 
commingling  of  gray  and  red,  producing  tlie  so-called  "gray-red  disk." 
and  often  there  is  a  decided  greenish  tinge,  rarely  a  blue  one. 

Grayness  of  the  optic  nerve  is  not  always  detected  by  ordinary- 
methods  of  examiiiation,  especially  in  the  (le(>per  layers  of  the  liisk, 
but  if  the  fun(his  is  cxuMiincd  by  means  of  proju'rly  regulated  illumina- 
tion, and  through  a  lens  which  neutralizes  any  error  of  refraction,  this 
deep  pallor  is  usually  evident.  It  is  important  to  employ  both  the 
direct  and  indirect  methods  of  examination,  and  the  concave  and  plane 
ophthalmoscopic  mirror. 


OPTIC-NERVE    ATROPHY  531 

(6)  Alteration  in  the  Center  of  the  Disk. — Sinking  of  the  surface  of 
the  disk,  varying  from  a  slight  depression  to  a  complete  excavation  (see 
page  399),  occurs  according  to  the  degree  of  degeneration  which  the 
nerve-fibers  have  experienced.  The  shape  of  the  excavation  depends 
somewhat  upon  the  presence  or  absence  of  a  normal  physiologic  cup. 
At  the  bottom  of  the  atrophic  excavation  the  mottling  of  the  lamina 
cribrosa  is  very  distinct  in  some  cases  of  atrophy;  in  others  it  is  not 
apparent,  the  center  of  the  disk  may  be  filled  in. 

(c)  Alterations  of  the  Margins  of  the  Disk  and  of  the  Scleral  Ring. — 
In  complete  atrophy  the  margin  of  the  optic  disk  is  unusually  distinct. 
In  the  atrophy  which  follows  a  neuritis  or  retinitis,  however,  the  marg- 
ins are  often  veiled  for  a  long  time. 

Undue  broadening  of  the  scleral  ring  indicates  shrinking  of  the  disk. 
Even  in  the  early  stages  of  spinal  atrophies  the  disk  may  be  surrounded 
by  a  broad  scleral  ring,  which,  taken  into  consideration  with  alteration 
in  the  color  of  the  papilla  and  contraction  of  the  color-field  (especially 
red  and  green) ,  affords  diagnostic  aid  in  the  study  of  gray  degeneration 
of  the  optic  nerve. 

2.  Changes  in  the  Vessels. — In  simple  atrophy,  while  there  may  be 
narrowing  of  the  vessels,  this  is  not  always  the  case,  and  certainly  not 
in  the  manner  seen  in  consecutive  atrophies.  Sometimes  the  arteries 
are  narrowed  and  the  veins  unchanged. 

In  neuritic  (consecutive)  atrophy  the  arteries  are  much  contracted 
and  the  veins  in  contrast  are  larger  than  usual,  often  retaining  some  of 
the  tortuosity  which  was  so  marked  a  feature  during  the  papillitic 
stage.  By  the  contraction  of  the  tissue  these,  too,  may  later  become 
narrowed.  Development  of  white  tissue  along  the  course  of  the  ves- 
sels, due  to  thickening  of  the  perivascular  lymph-sheath,  is  common  in 
this  form  of  atrophy. 

In  retinitic  and  choroiditic  atrophy  there  is  marked  contraction  of 
both  veins  and  arteries,  which  at  the  same  time  are  diminished  in 
number. 

3.  Changes  in  the  Surrounding  Eye-ground. — The  presence  of  altera- 
tions in  the  general  fundus  depends  entirely  upon  the  cause  of  the 
atrophy.  In  simple  gray  and  white  atrophy  such  signs  may  be  absent ; 
but  in  postpapillitic  and  retinitic  atrophy,  spots  of  degeneration,  mark- 
ing the  places  of  former  hemorrhages,  and  patches  of  pigment  heaping, 
are  commonly  seen. 

In  addition  to  these  ophthalmoscopic  changes  the  following  symp- 
toms occur: 

1.  Change  in  Central  Vision. — This  varies  from  a  slight  depreciation 
to  blindness,  and,  if  the  atrophy  is  bilateral,  is  usually  more  marked 
in  one  eye  than  in  the  other.  In  every  case,  where  this  is  possible, 
especially  in  early  cases  or  cases  of  doubtful  atrophy,  any  existing  re- 
fractive error  should  be  corrected  before  deciding  the  degree  of  deprecia- 
tion of  central  sight. 

2,  Change  in  Light-sense. — -Usually  it  has  been  found,  in  pure  optic- 
nerve  atrophy,  that  the  light-difference  is  increased,  but  the  light- 


532 


DISEASES    OF   THE    OPTIC    NERVE 


minimum  not  much  influenced.  P.  F.  Hay,  however,  has  also  observed 
considerable  increase  in  the  light-minimum.  Adaptation,  or  the  ac- 
commodation of  the  eye  to  varying  degrees  of  illumination,  is  greatly 
restricted,  for  example,  in  tabetic  optic-nerve  atrophy    (Lohmann). 

3.  Change  in  the  Field  of  Vision  for  White. — The  following 
changes  occur:  Concentric  contraction;  very  irregular  limitations 
presenting  large  re-entering  angles  (peripheral  scotomas):  ciuadrant- 
shaped  defects;  complete  loss  of  one-half  of  the  visual  field  (hemianop- 
sia); and  an  abnormal  blind-spot  in  the  center  of  the  field  (central 
iscotoma)  or  adjacent  to  it  (paracentral  scotoma). 

The  field  of  vision,  concentric  restriction  being  most  common,  does 
not  give  evidence  of  the  cause  of  the  atrophy,  although  it  may  afford 
information  of  the  localization  of  the  defect;  thus,  an  affection  of  the 

macular  fibers  will  produce  a  cen- 
tral scotoma.  In  spinal  atrophy 
the  limitation  more  frequently 
begins  at  the  outer  side  than  in 
other  situations. 

4.  Change  in  the  Field  of  Vision 
for  Colors. — There  is  always  a 
defect  in  color  vision.  I'sually 
there  is,  first,  contraction  of  the 
green  field,  then  of  the  red,  and 
afterward  of  the  blue  and  the 
yellow  fields.  In  late  stages  of 
optic-nerve  atrophy  color-sense 
is  abolished.  Occasionally  the 
perception  of  red  becomes  de- 
fective before  that  of  green  is 
influenced  by  the  atrophic  pro- 
cess. 

Generally  the  contraction  of 
the  color-field  is  much  greater 
than     that     of    the    white-field 


Fig.  233. — Field  of  vision  of  the  right  eye 
in  a  case  of  optic-nerve  atrophy.  The  white- 
field  is  slightly  contracted,  the  color-fields 
markedly  restricted  (compare  Fig.  43,  page 

87). 


(compare  page  417).  Central  vision  maybe  good,  the  white-fii'Ul  Init 
shghtly  or  not  at  all  affected,  and  yet  the  green  iiud  the  red  fi(>lds  may 
be  consideral)ly  contracted.  Hence  the  importance  of  combining  all 
these  examinations  before  deciding  wiiether  discoloration  of  the  papilla 
is  patiiologic  or  not. 

4.  Changes  in  the  Pupil.  -The  relations  of  the  ])U])il  to  the  actiim  of 
light  (icpend  upon  the  degree  of  atrophy.  In  many  cases  there  is  more  or 
less  perfect  paralytic  mydriasis,  and  when  the  atrophy  is  complete  the 
pupil  is  dilated  and  the  iris  motionless.  Kven  when  the  pupil  fails  to 
contract  under  the  influence  of  light  thrown  upon  the  retina,  i(  may  do 
so  in  the  act  of  convergence.      (See  also  page  til.) 

If  the  atroj)iiy  is  confined  to  one  eye,  no  reaction  will  occur  when 
the  light  falls  upon  the  corresponding  retina,  but  instant  contraction 
takes  place  when  this  is  directed  upon  the  letina  oi  the  opposite  (unaf- 


OPTIC-XERVE    ATROPHY  533 

fected)  side.  The  pupil  changes  in  spinal  disease  (tabetic  atrophy) 
have  been  described  (see  page  64.) 

Varieties  of  Optic-nerve  Atrophy. — 1.  Priynanj  Atrophy  {Some- 
times called  Gray,  Progressive,  Spinal,  or  Tabetic  Atrophy). — The  color 
of  the  disk  is  gray  or  white ;  sometimes  it  has  a  greenish  or  bluish  tint ; 
the  discoloration  is  associated  vnth  translucency,  and  the  stippling  of 
the  lamina  is  evident;  the  excavation,  if  it  exists,  is  complete  and 
saucer-like;  the  vessels  either  are  smaller  than  normal,  especially  the 
arteries,  or  they  are  unaffected  in  size;  the  edge  of  the  disk  is  sharply 
marked,  and  the  scleral  ring  clean  cut  all  around.  These  symptoms 
describe  the  fully  formed  atrophy. 

In  the  earlier  stages  of  the  degeneration,  according  to  the  late  Dr. 
W.  F.  Norris,  the  disks  are  of  a  dull  red  tint,  their  capillarit}^  is  super- 
ficial, and  the  deeper  layers,  in  the  neighborhood  of  the  lamina  cribrosa, 
are  gray  and  wanting  in  circulation.  There  is  often  sufficient  haze  of 
the  retinal  fibers  to  veil  the  scleral  ring.  •  Later  the  nerves  become  pallid, 
are  somewhat  woolly  superficially,  and  are  surrounded  on  all  sides  by 
broad  and  sharply  cut  scleral  rings.  The  larger  retinal  arteries  and 
veins  do  not  at  this  stage  present  any  appreciable  change  in  their 
caliber  or  appearance.  Both  eyes  usually  are  affected,  one  showing  a 
further  advance  of  the  degenerative  process  than  its  fellow. 

2.  Secondary  Atrophy. — The  color  of  the  disk  may  be  gray  and 
assumes  a  tint  not  greatly  dissimilar  from  the  atrophy  which  has  just 
been  described.  In  other  instances  the  color  is  more  decidedly  white. 
Both  sets  of  vessels  may  be  contracted,  usually  the  veins  being  less 
affected  than  the  arteries.  In  a  certain  number  of  cases  of  secondary 
atrophy  it  is  probable  that  preceding  the  degenerative  stage  there  is  a 
transient  congestion  of  the  disks;  certainly  this  is  true  in  those  cases 
where  there  has  been  a  retrobulbar  neuritis. 

3.  Consecutive  Atrophy. — (a)  Postpapillitic  Atrophy. — The  color  of 
the  disk  is  very  gray  or  white,  sometimes  with  a  decidedly  greenish  tinge 
or  even  a  blue  tint.  It  is  noticeable,  however,  that  the  translucency 
present  in  the  primary  form  of  atrophy  is  absent,  and  the  stippUng  of 
the  lamina  cribrosa  is  not  visible,  owing  to  the  existence  of  a  non- 
transparent  tissue  which  covers  it.  The  borders  of  the  disk  are 
slightly  veiled,  and  the  perivascular  lymph-sheaths  are  thickened. 
The  arteries  are  contracted,  the  veins  frequently  exhibiting  distinct 
tortuosity.     Retino-choroidal  changes  are  often  evident. 

(6)  Retiniiic  and  Choroiditic  Atrophy . — This  is  in  the  form  of  atrophy 
of  the  nerve  to  which  reference  has  already  been  made,  and  which 
follows  severe  forms  of  retinitis  and  choroiditis.  The  disk  has  a  dis- 
tinctly yellowish  tinge,  being  somewhat  waxy  in  appearance;  its 
borders  are  not  sharply  marked,  and  the  vessels  are  narrowed,  often 
to  a  great  degree. 

Causes. — In  addition  to  the  forms  of  atrophy  which  follow  inflam- 
mation of  the  nerve  {postpapillitic  a</-op/?y),  inflammation  of  the  choroid 
and  retina  {choroiditic  and  retinitic  atrophy),  embolism  and  thrombosis 
of  the  central  artery  and  thrombosis  of  the  central  vein  of  the  retina 


534  DISEASES   OF   THE    OPTIC   NERVE 

(embolic  and  thrombotic  atrophy),  the  varieties  which  are  gathered  under 
the  general  terms  primary  and  secondary  atrophy  require  mention. 

Privuiry  Atrophy  of  the  optic  nerve  occurs,  in  the  great  majority 
of  instances,  under  the  influence  of  diseases  of  the  spinal  cord,  and 
especiall}'  of  locomotor  ataxia.  It  is  frequent  in  general  paralysis  of  t  he 
insane  and  insular  sclerosis,  but  less  common  in  lateral  sclerosis.  There 
is  some  difference  of  opinion  in  regard  to  the  frequency  of  optic-nerve 
atrophy  in  locomotor  ataxia,  but  an  average  of  a  number  of  observa- 
tions gives  33.7  per  cent,  of  atrophies.  In  most  instances  it  begins  in 
the  preataxic  stage.  To  one  variety  of  the  affection,  in  which  the 
atrophic  process  precedes,  often  by  long  intervals,  the  ataxic  symp- 
toms, the  name  optic-nerve  type  of  tabes  dorsaUs  is  often  applied. 
Optic-nerve  atrophy  has  also  been  seen  with  Friedreich's  ataxia, 
amyotrophic  lateral  sclerosis,  chronic  myeUtis,  paralysis  agitans,  spastic 
spinal  palsy,  and  bulbar  palsy. 

Primary  atrophy  has  also  been  ascribed  to  the  influence  of  cold,  im- 
perfect nutrition,  disturbed  menstruation,  and  venereal  excesses.  It 
maj'  be  caused  bj-  diabetes,  sj'philis,  the  toxic  action  of  certain  drugs, 
and  excessive  hemorrhage  (see  also  page  552).  Its  association  with 
deformities  of  the  skull  has  been  described  (see  page  525).  Undoubt- 
edly it  may  be  due  to  arteriosclerosis,  the  thickening  of  the  arterial 
wall  closing  the  lumen  of  the  vessels.  Very  rareh'  it  has  resulted  from 
sclerosis  "^f  the  central  artery  of  the  retina.  Optic  nerve  atrophj-  in 
old  people  without  discoverable  const it-utional  or  local  cause  for  its 
existence  other  than  arteriosclerosis  is  not  very  uncommon,  but  not 
usually  far  advanced.  Such  nerve  changes  may  be  due  to  sclerosis 
of  the  nutrient  vessels  of  the  optic  nerve. 

Secondary  atrophy  appears  under  the  influence  of  compression  of  the 
optic  tract  and  the  optic  fibers — for  instance,  by  internal  hydro- 
cephalus or  by  pressure  of  a  tumor,  pituitary  neoplasm  or  struma, 
exostosis,  or  aneurysm  upon  the  chiasm.  It  is  also  said  to  occur  with 
meningtis  without  preceding  neuritis.  Optic  nerve  atrophj'  in 
patients  who  give  a  history  of  cerebral  symptoms  in  early  hfe  is  not 
infrequently  encountered  and  is  probably  the  result  of  a  chronic  menin- 
gitis fiom  which  recovery  has  taken  place;  such  atrophies  doubtless 
in  most  instances  are  the  result  of  preceding  neuritis  and  in  this 
sense  are  consecutive  and  not  secondary  atrophies.  Compression 
around  the  optic  foramen  is  likely  to  produce  secondary  atrophy  by 
direct  injuiy  to  the  fillers  of  the  optic  nerve.  Blows  on  the  head, 
especially  in  the  ncigliboihood  of  the  supra-orbital  foramen,  causing 
fracture  of  the  orbital  plate  or  periostitis,  may  be  followed  by  a  like 
result.  Atrophy  may  result  from  inflammation  of  the  axis  of  the 
nerve  posterior  1o  tlie  eyel^all. 

Pathologic  Anatomy.-    In  sinii)le  (1(  generation  as  it  occurs  in  tabes 
of  the  cord  the  ncive-fibers  lose  their  medullary  sheaths  and  arc*  con- 
verted into  fine  fibrilhe,  between  which  are  numerous  fatty  granular  , 
cells;  no  true  inflammatory  process  appears.     Later  all  nervous  ele-           § 
ments  mav  disappear.     Tabetic  atrojihy  of  the  optic  neiNc  has  been 


( 


Plate  VI I. 


Primary  atrophy  of  the  optic  nerve. 


OPTIC-NERVE    ATROPHY  535 

ascribed  to  disease  and  disappearance  of  the  retinal  ganglion  cells 
(Ward  Holden),  but  from  a  comparison  of  the  visual  fields  in  glau- 
coma with  those  in  tabetic  atrophy  Ronne  concludes  that  the  lesion 
is  in  the  optic  nerve-fibers,  and  Stargardt  seems  to  have  demonstrated 
that  an  exudative  process  in  the  chiasm  and  nerves  procedes  the  de- 
generative one.  In  postneuritic  atrophy  there  is  considerable  new- 
formed  connective  tissue  in  the  nerve-head  and  trunk,  through  which 
run  the  thickened  vessels;  the  sheaths  of  the  nerve-fibers  degenerate, 
break  down  into  fine  drops,  and  the  nerve-fibers  become  varicose  and 
either  shrink  or  disappear.  The  septa  are  much  thickened,  and  in  ad- 
vanced cases  the  nerve  becomes  a  narrow,  purely  connective-tissue  cord. 
Diagnosis. — The  student  is  warned  not  to  mistake  the  pallor  of  age 
for  the  pallor  of  disease;  not  to  mistake  a  large  physiologic  cup,  with 
its  margin  shelving  toward  the  temporal  border  of  the  disk,  for  an 
atrophy  confined  to  half  of  the  optic  papilla;  and  not  to  mistake  small 
patches  of  retained  marrow-sheath  for  atrophic  changes. 

Not  every  gray  disk,  with  an  unusually  marked  scleral  ring,  is  indic- 
ative of  atrophy,  and  it  is  only  when  these  appearances  accord  with 
the  other  manifestations  of  beginning  degeneration  that  the  diagnosis 
of  incipient  atrophy  is  justified.  The  Wassermann  test  of  the  blood 
and  of  the  spinal  fluid  should  always  be  employed,  and  a  stereoscopic 
.r-ray  plate  should  be  made  in  order  to  determine  the  condition  of  the 
pituitary  region  and  the  accessory  sinuses  of  the  skull;  in  short  a 
thorough  examination  in  all  respects  should  be  made  in  each  case 
of  optic  nerve  atrophy. 

The  differential  points  between  a  chronic  glaucoma  and  an  optic- 
nerve  atrophy  have  been  described  (see  page  417),  and  also  the  relation 
of  light-sense  to  optic-nerve  atrophy.  According  to  Lohmann's  in- 
vestigations all  those  cases  with  a  disproportionately  great  affection  of 
adaptation  appear  to  belong  to  the  group  of  glaucomatous  degenera- 
tions in  contrast  to  other  forms  of  atrophy. 

Course  and  Prognosis. — The  course  of  optic-nerve  atrophy  is  usu- 
ally a  slow  one,  lasting  for  months  and  it  may  be  years,  depending  to  a 
certain  extent  upon  the  original  cause  of  the  atrophy.  Exceptions  to 
this  statement  concern  those  forms  of  atrophy  which  follow  injury 
(fracture  at  the  base  of  the  skull  or  at  the  apex  of  the  orbit),  where 
the  process  may  rather  quickly  develop.  Even  in  these  cases  a  week 
or  more  may  elapse  before  ophthalmoscopic  atrophy  is  visible. 

The  prognosis  is  unfavorable  in  primary  or,  as  it  is  sometimes  called, 
progressive  atrophy,  the  tendency  being  to  a  gradual  deterioration  of 
sight  with  shrinkage  of  the  field  of  vision,  until  blindness  is  the  result. 
The  prognosis  of  a  consecutive  atrophy  depends  entirely  upon  the 
amount  of  damage  which  is  likely  to  ensue  from  the  shrinking  which 
follows  during  the  subsidence  of  the  neuritis.  In  the  forms  of  atrophy 
which  follow  an  inflammation  of  the  axis  of  the  nerve  the  prognosis 
is  better. 

Treatment. — This  depends  upon  the  cause.  If  syphilis  is  present, 
the  usual  remedies  are  indicated;  but  mercury  is  useless  in  advanced 


536  DISEASES    OF   THE    OPTIC    NERVE 

cases,  oven  in  syphilitics.  W'liile  salvarsan  or  neosalvarsan  exercise  no 
detrinu'iital  effect  on  a  healtliy  optic  nerve,  at  one  time  it  was  main- 
tained that  salvarsan  exerted  an  evil  inHuenc(>  on  tabetic  atrophy. 
Recently  this  contention  has  been  set  aside  and  there  are  now  a  number 
of  observations  on  record  which  tend  to  show  that  neosalvarsan.  if 
used  earl}'  and  while  color  perception  is  still  good,  re{)resents  a  thera- 
peutic agent  of  value  in  the  treatment  of  ta])etic  atrophy.  Sdlrar- 
sanized  serum  injected  intiaspinously  (Swift-Kllis  method)  may  do 
good  if  employed  before  the  degenerative  process  has  begun  and  it 
and  other  methods  of  intraspinous  and  intracranial  injections  of  sal- 
varsan should  b(>  given  a  trial.  ^  It  is  vitally  important  that  syphilitics 
from  the  earliest  manifestation  of  their  infection  should  be  systemat- 
ically and  repeatedly  examined  from  the  ophthalmic  standpoint. 
Strychnin  has  been  much  employed  administered  in  full  doses,  prefer- 
ably by  the  hypodermic  method;  it  may  be  enforced  by  nitroglycerin. 
Other  remedies,  according  to  the  cause,  are  iodid  of  potassium,  nitrate 
of  silver,  phosphorus,  arsenic,  iron,  santonin,  lactate  of  zinc,  hypo- 
dermics of  antipyrin  (Valude),  and  injections  of  organic  liquids,  all 
of  doubtful  value.  Negative  galvanism  has  been  advised,  and  good 
results  have  been  reported  by  L.  W.  Fox,  Ziegler.  RatlclifTe,  F.  W. 
Coleman,  and  many  other  observers.  Coleman  especially  recom- 
mended the  sinusoidal  current,  a  binocular  electrode  being  placed  over 
the  eyes  and  an  oval  pad  to  the  nape  of  the  neck.  The  treatment 
should  take  place  for  twenty  minutes  each  day.  High-freciuency 
currents  have  been  advocated  and  they  should  l)e  tried.  In  a  few 
instances  suspension  is  said  to  have  been  followed  by  improvement 
of  vision  in  tabetic  atrophy.  There  is  no  satisfactory  evidence  that 
radium  and  the  Rontgen  rays  are  useful  therapeutic  agents  in  the 
treatment  of  optic-nerve  atrophy. 

Hereditary  Optic=nerve  Atrophy  (Ilervdiiary  Optic  Xci(riti.-<]. — 
A  remarkable  type  of  optic-nerve  atrophy,  that  is,  of  the  papilloma- 
cular  bundle  (retrobulbar  neuritis),  first  systematically  described  by 
Leber  (Leber's  disease),  is  hereditary,  and  may  apjiear  for  a  number  of 
generations  usually,  but  not  always,  in  the  mali'  meml)ersof  the  family. 
It  is  transmitted  by  unaffected  females.  An  alTected  male  seUKmi 
transmits  the  disease  (Nettleshij)).  The  disease  generally  begins  be- 
tween the  eighteenth  and  twentj^-third  year,  but  has  been  observed  as 
early  as  the  fifth  year  and  delayed  as  late  as  the  sixty-seventh  year. 
According  to  Norris,  there  are  three  stages  of  the  atTei-tion:  (1)  Stag*' 
of  edema  and  congestion  of  the  disk;  (2)  stage  of  gray  iliseoloration  of 
the  nerve-head;  and  (3)  stage  of  pronounced  atrophy.  The  condition 
is  usually  symmetric;  both  eyes  being  affected  at  the  s;nne  time,  or 
there  may  be  an  interval  of  some  weeks.  Central  scttlonias  are  com- 
monly present  and  are  usually  permanent.  In  .\rnold  Knapp's  cases 
the  first  generation  presented  central  scotomas  and  peripheric  contrac- 
tions of  tile  visual  fields;    but  in  the  second  and  third  generations  no 

'  ('onsult  Diagnosis  iiiid  Tic.-it  inciit  of  l.ticiic  lii\ ois  i-iiu'iit  of  lli«'  Optic  l*ntli_ 
wiiVH  hy  M.  .1.  ScliiMiilxTK.  'I'liiiis.  ,\riicr.  (tplilli.  Sue,  xvii,   \\)l\i. 


ORBITAL    OPTIC    NEURITIS  537 

central  scotomas  developed.  The  subjects  of  this  remarkable  disease 
may  have  headaches,  tremors,  vertigo  and  epileptic  attacks.  The 
incidence  of  the  affection  may  be  at  the  time  of  sexual  development 
or  at  the  time  of  sexual  decay.  J.  Herbert  Fisher  and  James  Taylor 
have  noted  by  means  of  aj-ray  examination  changes  in  the  sella  turcica 
and  similar  observations  have  been  made  by  Pancoast  and  Zentmayer. 
Usually  treatment  has  little  or  no  effect,  but  improvement  and  even 
recovery  have  been  reported  (Cargill). 

Orbital  Optic  Neuritis  (Retrobulbar  or  Axial  Neuritis;  Central 
Amblyopio) . — In  contradistinction  to  the  optic  neuritis  which  is  spe- 
cially localized  at  the  intra-ocular  end  of  the  nerve,  an  inflammation 
occurs  in  the  orbital  part  of  the  optic  nerve,  which  is  called  orbital  optic 
neuritis — retrobulbar  or  axial  neuritis.  It  appears  in  an  acute  and  a 
chronic  type. 

1.  Acute  Retrobulbar  or  Axial  Neuritis. — The  symptoms  of  this 
affection  are  the  following:  Obscuration  of  vision,  beginning  always  in 
the  center  of  the  visual  field,  and  rapidly  progressing  in  from  one  to 
eight  days  to  complete  or  nearly  complete  blindness;  at  first  negative 
ophthalmoscopic  appearances,  later  blurring  of  the  margins  of  the  disk, 
hyperemia  of  its  surface,  and  sometimes,  in  severe  cases,  diminished 
caliber  of  the  retinal  arteries  and  fulness  and  pulsation  of  the  retinal 
veins;  distinct  pain  on  movement  of  the  eyeball,  or  when  the  globe  is 
pressed  backward  into  the  orbit.  The  central  scotoma  does  not  always 
either  expand  to  the  limits  of  the  visual  field  or  remain  in  its  central 
position  with  exactness.  Ronne  has  described  a  "shifting  of  the 
visual  field  defect"  at  different  periods  in  the  course  of  the  disease. 

The  affection  appears  to  depend  upon  an  interstitial  neuritis,  most 
severe  in  the  optical  canal,  and  at  first  chiefly  located  in  the  papillo- 
macular  tract,  from  which  it  may  extend,  however,  until  the  whole 
diameter  of  the  nerve  is  involved.  If  the  process  is  unchecked,  neces- 
sarily secondary  degeneration  of  the  nerve-fibers  takes  place.  There  is 
also  degeneration  in  the  ganglion  cells  of  the  macula. 

Cause. — The  determining  cause  of  the  disease  is  the  presence  in- 
the  blood  of  an  infecting  agent  existing  in  association  with  some  dis- 
ease— for  example,  rheumatism,  dysentery,  intestinal  sepsis,  tuber- 
culosis, gout,  syphihs,  influenza,  diabetes,  small-pox,  and  scarlet  fever; 
or  coming  directly  from  a  focus  of  infection  in  the  mucous  membrane 
of  the  nose,  the  mouth  (the  teeth),  the  tonsils,  the  ethmoid  cells, 
the  sphenoid  sinus  and  other  sources  of  focal  sepsis;  or  arising  as  the 
direct  result  of  an  inflammatory  process  in  the  orbit — e.  g.,  cellulitis, 
or  in  the  optic  canal — for  example,  periostitis,  gummatous  deposits, 
etc.  The  disease  has  also  been  attributed  to  certain  toxic  agents,  such 
as  alcohol,  lead,  etc.;  to  menstrual  disturbances,  especially  sudden 
suppression  of  the  menses,  to  auto-intoxication,  and  to  overwork  and 
prolonged  eye-strain.  Not  only  may  retrobulbar  neuritis  be  caused 
by  suppuration  ethmoiditis,  but  it  may  arise  in  connection  with  hyper- 
plasia of  the  ethmoid  bone  (Vail).  A  certain  number  of  cases  exist 
for  which  no  cause  can  be  ascertained.     Nettleship  divided  cases  of 


538 


DISEASES    OF   THE    OPTIC    NERVE 


retrobulbar  neuritis  into  two  groups:  the  idiopathic,  in  which  the 
disease  starts  in  the  nerve  itself,  and  syniptonudic,  in  which  it  is  com- 
municated to  the  nerve  by  the  surrounding  tissues. 

This  disease  may  be  part  of  the  symptomatology  of  multiple  scle- 
rosis and  of  acute  or  subacute  myelitis,  and  is  in  these  circumstances  of 
most  serious  prognostic  import.  Retrobulbar  neuritis  ipsolateral  to 
the  lesion  has  been  recorded  as  a  symptom  of  tumor  or  abscess  of  the 
frontal  lobe  (Paton,  F.  Kennedy);  choked  disk  may  be  present  in 
opposite  eye.     The  author  has  observed  several  cases  of  this  character. 

The  course  of  the  disease  may  })o  rapid  or  fulminant,  as  it  is  called. 
It  is  sometimes  bilateral,  but  more  frcciucntly  unilateral,  or  a  long 
interval  may  occur  between  the  involvement  of  the  first  and  second  eye. 
Relapses  may  occur,  and  the  affection  may  alternate  between  the  two 
eyes.     As  pointed  out  by  jMr.  ^Marcus  Gunn,  there  is  marked  analogy 


Fig.  234. — Central  scotoma  from  a  case  of  tobacco  amblyopia:  /,  Fixation;  6,  blind-spot. 


between  axial  inflammation  of  the  optic  canal  and  paralj'sis  of  the 
facial  nerve  (Bell's  palsy)  when  its  trunk  is  involved  in  its  tortuous 
course  through  the  wall  of  the  skull.  Indeed,  as  the  author  has  shown, 
retrobulbar  inflammation  may  be  preceded  by  an  attack  of  peripheral 
facial  palsy,  either  upon  the  same  or  the  opposite  side. 

Although  the  prognosis  must  always  be  guarded,  in  the  majority  of 
instances  the  tendency  is  to  recovery,  and,  under  careful  treatment, 
to  perfect  recovery.  In  severe  cases,  jiermanont  pallor  of  all  or  part 
of  the  optic  nerve,  defective  central  vision  for  colors,  central  scotoma, 
and  contraction  of  the  peripheral  field  may  remain.  The  fact  that 
retrobulbar  neuritis  may  indicate  the  future  onset  of  disseminated 
sclerosis  should  not  be  forgotten.  It  may  precede  the  other  symptoms 
by  many  years.  According  to  Marx,  it  may  dev(^lop  in  a  certain  j)er- 
centage  of  the  cases  from  one  to  seven  years  after  apparent  recovery. 
Shumway's  study  of  retrobulbar  neuritis  dependent  on  focal  infection 
followed  by  insular  sclerosis  is  most  suggc^stive  and  important.  Stark 
has  made  similar  observations.  Tiieic  is  also  a  variety  of  the  dis(>ase 
due  to  exposure,  nicnst  rual  (Ust  urbances,  and  rheumat  ism.  in  which  t  he 
same  sj'mplonis  appear  as  those  previously  (iescril)ed,  but  all  of  a 
milder  type  and  all  more  ;inienalile  to  treatment. 


ORBITAL    OPTIC    NEURITIS  539 

Treatment. — In  so  far  as  possible  the  patient  must  be  removed 
from  the  influence  of  the  cause.  If  the  affection  has  occurred  during 
the  course  of  an  acute  infectious  disease,  the  treatment  of  this  par- 
ticular malady  is  indicated.  In  other  circumstances  the  best  results 
follow  active  diaphoresis,  full  doses  of  salicylic  acid,  the  free  use  of 
mercury,  the  iodids,  and  counterirritation  on  the  temple.  No  patient 
with  retrobulbar  neuritis  should  escape  searching  examination  of  the 
nasopharynx,  the  ethmoid,  frontal,  and  sphenoid  sinuses.  If  purulent 
disease  is  found,  operation  with  suitable  drainage  may  speedily  relieve 
the  ocular  condition;  if  this  is  neglected,  blindness  may  result.  (See 
also  page  647.)  Eetrobulbar  neuritis  of  tuberculous  origin  has  been 
relieved  by  injections  of  tuberculin  (Igersheimer).  The  affection 
may  be  due  to  syphilis  and  therefore  the  proper  serological  tests 
should  always  be  made  and  treatment  directed  according  to  the  result. 

2.  Chronic  Retrobulbar  or  Axial  Neuritis  (Tobacco  Amblyopia; 
Toxic  Amblyopia) . — The  clinical  symptoms  of  this  affection  are  as  fol- 
lows: Diminution  of  sight,  associated  with  fogginess  in  the  center  of 
the  field  of  vision,  unimproved  by  glasses  and  most  noticeable  in 
bright  light;  reduced  acuteness  of  vision,  which  varies  from  %  to 
counting  fingers;  negative  ophthalmoscopic  appearances  or  pallor  of 
the  temporal  half  or  of  a  quadrant-shaped  portion  of  the  papilla; 
normal  peripheral  boundaries  of  the  field  of  vision;  symmetric  central 
color  scotomas,  especially  for  red  and  green,  usually  oval  in  shape, 
stretching  from  the  fixing-point  to  the  blind-spot,  and  rarely  passing 
much  to  the  nasal  side  of  the  former;  defective  light-sense.  The  sco- 
toma, which  is  the  most  important  of  the  symptoms,  represents  a  red- 
green  blind  area,  and  commonly  the  extent  of  green-blindness  is  greater 
than  that  of  red,  which,  in  its  turn,  may  be  surrounded  by  an  area  of 
imperfect  color-sense.  Sometimes  its  beginning  is  a  small,  easily 
overlooked  scotoma  exactly  over  the  fixing-point  (Groenouw).  After 
the  typical  egg-shaped  scotoma  is  developed,  the  process  may  cease, 
or  there  may  be  a  stage  of  progression  characterized  by  an  increase  in 
the  size  of  the  color  defect,  usually  above,  until  it  meets  the  limit  of 
the  red  field;  that  is,  the  scotoma  has  "broken  through."  In  severe 
cases  there  may  be  scotoma  for  blue  and  yellow.  Finally,  small 
absolute  defects  may  be  found,  and  in  neglected  cases,  or  in  those  not 
typically  toxic,  the  entire  scotoma  may  become  absolute.  The  periph- 
ery of  the  visual  field  is  not  always  intact,  and  contractions  may  be 
found  if  the  tests  are  made  under  diminished  illumination.  According 
to  Dorrell  and  Herbert  Fisher  the  sensory  pupil  reflex  is  much  dimin- 
ished or  entirely  absent  in  toxic  amblyopia. 

Causes. — The  most  important  drugs  and  toxic  substances  which 
may  be  responsible  for  the  clinical  symptoms  which  have  just  been 
detailed  are  tobacco  and  alcohol,  either  singly  or  combined,  stramo- 
nium, cannabis  indica,  thyroid  extract,  chloroform,  chloral,  opium, 
bisulphid  of  carbon,  nitrobenzol,  carbon  monoxid  and  other  poisonous 
gases,  arsenic,  atoxyl,  lead  and  iodoform.  Of  the  substances  men- 
tioned, tobacco  is  the  one  most  often  responsible  for  this  affection,  but 


540 


DISEASES    OF   THE    OPTIC    NERVE 


as  the  users  of  tobacco  are  also  usually  consumers  of  alcohol  it  is 
difficult  to  separate  the  etiologic  influence  of  these  two  drugs,  and 
hence  the  name  intoxicati&n  or  toxic  amblyopia  is  used  to  describe  a 
central  amblyopia  which  may  be  due  to  either  of  these  substances  or 
to  their  combined  influence.  A  pure  tobacco  amblyopia,  which  the 
author  l)elieves  he  has  observed  is  uncommon;  indeetl.  some  observers 
deny  its  existence.  Although  usually  bilateral,  a  few  instances  have 
been  recorded  in  which  the  symmetric  development  of  tobacco  ambly- 
opia has  been  delayed.     It  is  rare  before  the  thirty-fifth  year. 

Chronic  axial  neuritis  is  also  caused  by  toxic  agents  elaborated  in 
the  cause  of  general  diseases,  for  instance  diabetes  (page  551),  or 
intestinal  sepsis.  The  subjects  of  pellagra  may  have  pallid  disks 
and  central  relative  scotomas  (Calhoun).  Even  in  these  circumstances 
it  is  not  always  possible  to  eliminate  the  influence  of  tobacco.     Also 


Fig.  235. — Sections  of  the  ri^lit  optic  nerve  in  a  case  of  toxic  amblyopia,  showing 
degeneration  of  the  papillomacular  bundle  (Weigert's  stain):  A,  Transverse  section  of 
the  optic  nerve  13  mm.  behind  the  globe;  B,  transverse  section  of  the  optic  nerve  in  the 
region  of  the  optic  foramen. 

in  syphilis,  sinus  disease  antl  other  infections  although  the  signs 
of  acute  neuritis  may  be  absent,  the  interpretation  of  the  axial  de- 
generation maj^  be  a  relative  scotoma  such  as  has  been  described. 

The  pathologic  lesion  which  causes  this  form  of  amblyopia,  acconl- 
ing  to  I'lithoff  and  other  observers,  is  an  interstitial  iiiflanunation  of  the 
papilloniacular  fibers  of  the  optic  nerve.  These  fibers,  t  raced  l)y  means 
of  their  degeneration,  consist  of  a  bundle  shaped  like  a  triangle  near 
the  eye,  with  its  base  in  the  lower  and  outer  part  of  the  nerve,  and  its 
apex  at  the  central  vessels.  Gradually  it  passes  to  the  center  of  the 
nerve,  which  it  reaches  in  the  optic  canal.  I'inally,  it  can  i)e  followed 
into  the  chiasm  and  tracts.  Nuel  and  others  believe  (hat  eential  toxic 
scotoma  is  not  caused  primarily  by  a  neuritis  of  the  macular  bundle, 
but  represents  a  disease  of  the  macula  lutea,  causing  degeneration  of 
its  cells,  and  that  the  optic  nerve  changes  are  secondary  to  d(>struction 
of  the  nerve-cells  in  the  macula.  The  inv(>s(igations  of  Hiich-llirsch- 
feld  leail  him  to  doubt  that  the  process  depiMuls  upon  a  primary  inter- 
stitial inflamnuition  of  tiie  optic  nerve.  He  believes  that  there  is  a 
primary  involvement  of  the  nervous  elements  of  the  nerve  and  retina, 
with  an  accompanying  |)roliferat ion  of  tlie  glia  and  increase  in  the 
connective  tissue.     Schieck  concludes  that   the  disease  begins  witii  an 


INJURY    OF    THE    OPTIC    NERVE  541 

alteration  of  the  blood-vessels  within  the  optic  nerve,  and  as  the  central 
fibers  are  less  liberally  supphed  with  blood,  they  are  the  first  to  be 
afi"ected.  While  vessel  disease  may  have  an  important  bearing  on  this 
affection,  a  direct  action  of  the  toxin  on  the  nervous  elements  seems 
undoubted. 

Course  and  Prognosis. — The  course  is,  as  its  name  indicates,  a 
chronic  one,  but  the  prognosis  of  the  tobacco  and  alcoholic  cases  is  good, 
provided  the  patients  present  themselves  at  an  early  enough  stage  for 
treatment.     In  rare  instances  complete  optic-nerve  atrophy  results. 

Treatment. — This  consists  in  total  abstinence  from  the  use  of 
tobacco  and  alcohol,  and  in  the  earlier  stages  this  alone  will  be  suf- 
ficient to  bring  about  a  cure.  Later,  a  remedy  of  value  is  strychnin, 
which,  as  in  other  instances  of  optic-nerve  disease,  should  be  pushed 
to  its  full  physiologic  limit.  In  order  to  help  in  the  absorption  of 
inflammatory  products,  iodid  of  potassium  may  be  given.  Regulation 
of  diet  and  free  diaphoresis  are  valuable  measures.  Sinusoidal 
galvanism  applied  over  the  eye  with  a  properly  constructed  electrode 
appears  to  act  favorably.  Examination  of  the  urine,  as  the  author 
and  David  Edsall  have  shown,  is  apt  to  reveal  an  excessive  excre- 
tion of  enterogeneous  decomposition  products,  and  with  its  restoration 
to  normal,  under  the  influence  of  proper  dietetic  regimen,  the  eye 
conditions  improve.  The  patients  should  drink  water  freely.  Tem- 
porary improvement  occurs  under  the  influence  of  inhalations  of 
nitrite  of  amyl,  and  the  circulation  of  the  optic  nerve  may  be  stimulated 
by  the  exhibition  of  digitalis  and  nux  vomica.  Lecithin  has  been  recom- 
mended in  the  treatment  of  tobacco  amblyopia  (H.  de  Waele). 

Necessarily,  if  some  poison  other  than  alcohol  or  tobacco  is  active, 
the  patient  must  be  removed  from  its  influence. 

Injury  of  the  Optic  Nerve. — This  may  be  produced  by  the  en- 
trance of  a  foreign  body  into  the  orbit,  for  example,  the  end  of  a  sharp 
stick,  or  from  a  fracture  involving  the  bony  wall  of  the  orbit  or  base  of 
the  skull  or  from  the  thrust  of  a  knife.  Atrophy  of  the  optic  nerve  is  the 
result.  Indirect  injury  of  the  optic  nerve  may  be  caused,  as  Evans 
has  shown,  by  a  blow  in  the  region  of  the  external  angular  process  of  the 
frontal  bone.  The  primary  impairment  of  vision  and  loss  of  the 
temporal  field  may  be  followed  by  atrophy  of  the  nerve.  During  the 
past  war  there  were  many  optic  nerve  injuries  as  the  result  of  the  pas- 
sage of  a  missile  through  the  posterior  part  of  the  orbit  causing  incura- 
ble blindness. 

Avulsion  of  the  optic  nerve  was  not  infrequent.  After  the  hemor- 
rhage following  such  an  accident  absorbs  a  traumatic  excavation  is 
visible — a  kind  of  "coloboma  or  surgical  conus,"  as  Lagrange  calls  it. 
This  may  be  filled  up  later  with  proliferated  connective  tissue.  The 
retinal  vessels  although  they  may  disappear,  may  in  some  cases  remain. 
This  has  been  often  noted,  and  recently  well  figured  and  commented 
upon  by  Edward  Jackson.  Parsons  states  the  vessels  refill  through 
direct  and  indirect  cilioretinal  anastomosis,  the  blood  being  derived 
from  intact  anterior  and  posterior  ciliary  arteries.     It  is  not  necessary 


542 


DISEASES    OF   THE    OPTIC    NERVE 


that  there  shall  be  a  division  of  the  nervo  sheath  as  a  factor  in  the 
production  of  avulsion  (W.  T.  Lister  and  M.  L.  Hine). 

Tumors  of  the  Optic  Nerve. — These  usually  are  divided  into  intra- 
dural and  extradural  tumors.  Of  the  former,  102  cases  have  been  col- 
lected by  W.  G.  M.  Byers  in  his  notable  monograph  on  this  subject, 
and  they  include  fibroma,  sarcoma,  glioma,  endotheUoma.  gumma, 
tubercle,  and  myxoma.^  Of  the  latter  (extradural  tumors)  Parsons 
has  been  able  to  find  12  undoubted  cases,  and  of  these,  9  were  almost 
certainly  endotheliomas. 


Fig.  236. — Avulsion  of  the  optic  nerve  (from  a  i)atient  in  the  I'niversity  Hospital). 

The  symptoms  are:  Exoplithalmos,  tlu^  cvo  being  {nishcd  downward 
and  forward,  the  motion  of  the  globe  l)eing  unaffected,  and  defective 
vision,  which  is  an  early  manifestation.  The  growth  is  slow  and  pain- 
less, but  sometimes  a  suppurative  keratitis  may  result.  The  oph- 
thalmoscope reveals  distended  veins,  edema,  and  eiioking  of  the  papilla 
followed  later  by  wiiite  atrophy  and  shrinking  of  the  vessels.  Atrophy 
of  the  pajjillomacular  bundle  and  central  scotoma  may  occur,  as  in  one 
of  the  author's  cases.     With  intradural  tumor.^  fh(>  movement  of  the 

'  Hudson  in  1912  analyzed  154  cases  collected  from  the  literature,  and  clas.sifies 
118  of  them  as  plioinas,  or  as  prohahly  gliomatous.  Hudson  and  Verhoeff  olijcrt 
to  the  terms  "intradural"  and  "extradural"  tumors.  N'erlutrlT's  cla.ssififation  is: 
tumors  arising  in  the  nerve  stem  (intradural),  and  tumors  arising  in  thi>  nerve 
sheath  (extradural).  AceordiiiK  to  him,  the  most  common  tumors  of  the  optic 
nerve  are  gliomas.  (Tran.sactions  of  the  Section  of  Opiith.almology,  .Vmer.  NIed. 
Assoc,  19*21.) 


HYALINE   BODIES    (dRUSEN)    IN    THE    PAPILLA 


543 


eye  is  usually  restricted  in  the  opposite  direction  to  any  modification 
of  the  proptosis  directly  forward  (Parsons) . 

Treatment. — In  most  instances  the  eyeball  must  be  removed  with 
the  tumor,  but  occasionally  the  globe  can  be  saved  (11  times  in  Finlay's 


Fig.  237. — Intradural  tumor  of  the  optic  nerve. 

collection — subsequent  loss  in  4  cases).  Exenteration  of  the  orbit  has 
been  necessary,  primarily,  in  a  few  instances,  and  secondarily  on  ac- 
count of  local  recurrence.     Even  after  enucleation,  and  sometimes  at 


Fig.  238. — Microscopic  section  of  a  nerve-head  containing  hyaline  bodies  (from  a  photo- 
micrograph). 

a  period  long  removed  from  the  time  of  operation,  the  growth  has  re- 
curred and  death  may  occur  from  intracranial  involvement.  Since  the 
introduction  of  Kronlein's  operation  and  its  modifications  exploration 
of  the  orbit  has  been  greatly  facilitated  and  the  opportunity  of  saving 


544  DISEASES   OF   THE    OPTIC    NERVE 

the  eyeball  has  been  increased.     A.    Kiiapp  and  Reese  report  satis- 
factory results  after  a  Kr(>iileiii  operation. 

Hyaline  Bodies  (Drusenj  in  the  Papilla. — This  affection  is 
characterized  by  the  formation  in  the  optic  papilla  of  small  excrescences 
or  globular  formations,  which  are  sometimes  described  as  colloid  masses. 
The  bodies  are  variously  shaped,  chiefly  roundish,  of  a  yellowish-white 
or  bluish-gray  color,  forming  a  mulberry-like  appearance  and  present- 
ing a  striking  ophthalmoscopic  picture.  They  may  occur  at  any  age  of 
life,  sometimes  in  association  with  choroidoretinitis,  optic  neuritis,  and 
optic-nerve  atrophy,  but  also  in  eyes  free  from  other  pathologic  changes 
and  with  perfectly  normal  vision.  Two  views  have  been  maintained  in 
regard  to  the  origin  of  the  drusen:  (1)  That  they  are  hyaline  excres- 
cences of  the  lamina  vitrea  of  the  choroid  which  become  eml)edded  in 
the  head  of  the  optic  nerve,  and  (2)  that  they  have  nothing  in  common 
with  the  choroidal  excrescences,  but  are  a  special  pathologic  process 
confined  to  a  small  portion  of  the  optic  nerve.  The  microscopic  studies 
of  the  author  indicate  that  the  latter  view  is  the  more  nearly  correct 
of  the  two.  The  exact  nature  of  the  material  thus  deposited  has  not 
been  determined.  One  investigation  by  Hirschberg  and  Cirincione 
indicates  that  the  bodies  are  amorphous  and  organic,  and  their  compo- 
sition appeared  most  to  resemble  that  of  elastin.  They  may  undergo 
calcification,  hke  the  cheesy  nodules  in  the  lung.  According  to  Par- 
sons, "Drusenbildungen"  upon  the  optic  disk  represent  exudations 
which  have  been  laid  down  in  layers. 


CHAPTER  XVII 

AMBLYOPIA,  AMAUROSIS,   AND    DISTURBANCES  OF  VISION 
WITHOUT  OPHTHALMOSCOPIC  CHANGES 

Amblyopia  and  amaurosis  are  terms  which  signify  dim?ie.ss  of 
vision,  the  former  being  used  to  describe  obscurity  of  sight,  and  the  latter 
the  more  advanced  condition  of  loss  of  vision.  Although  these  terms 
usually  describe  defective  vision  unexplained  by  lesions  in  the  eye  or 
refractive  error,  this  limitation  is  not  strictly  followed,  and  eyes 
blinded  by  inflammator}'  disease  are  sometimes  described  as  amaurotic.^ 

Modern  methods  of  examination  have  greatlj^  lessened  the  number 
of  conditions  to  which  the  older  writers  applied  the  words  "amblyopia" 
and  "amaurosis."  Amblyopia  is  a  symptom  and  describes  the  defect- 
ive vision  from  which  the  patient  suffers.  This  may  be  due  to  func- 
tional disturbance  or  to  disease  of  the  visual  apparatus  (retina,  optic 
nerve,  or  visual  centers) ,  and  may  be  unassociated  with  changes  in  the 
eye-ground:  or  there  may  be  atrophy  of  the  optic  nerve. 

Amblyopia  may  be  congenital  or  acquired;  temporary  or  permanent; 
symmetric  or  non-symmetric. 

Congenital  Amblyopia. — This  term  is  used  to  describe  that 
variety  of  defective  vision  which  for  the  most  part  is  uncomplicated 
with  fundus  lesions,  although  sometimes  the  papilla  is  discolored  and 
the  macula  deeply  pigmented,  and  there  is  a  scotoma,  either  small  and 
absolute,  or  larger  and  for  colors  alone.  According  to  Heine,  a  central 
scotoma  can  be  demonstrated  in  90  per  cent,  of  the  cases.  The  faulty 
vision  has  existed  from  birth,  and  often  high  grades  of  refractive 
error,  especially  hyperopia  and  astigmatism,  are  present,  and  clear 
images  have  never  been  focused  upon  the  retina.  Correction  of  the 
optical  error  usually  fails  to  improve,  materially,  the  vision;  the  retinal 
images  continue  to  be  defective.  In  very  young  patients  an  eye  of  this 
character  may  occasionally  be  trained  to  more  nearh'  perfect  vision 
after  a  proper  correction  of  the  refractive  error,  and  this  attempt  should 
always  be  made.-  Naturally,  before  the  diagnosis  of  congenital  am- 
blyopia is  established,  the  possible  influence  of  orbital,  nasal  sinus,  and 
central  nervous  disease  must  be  eliminated.  The  origin  of  congenital 
amblyopia  is  obscure;  an  anatomic  basis  for  the  condition  has  not  been 

'  The  term  "amaurosis"  is  also  applied  to  certain  cases  of  blindness  in  young 
children  dependent  upon  hereditary  influence,  syphilis,  tuberculous  disease,  and 
meningitis.     The  eye-grounds  may  or  may  not  be  diseased. 

-  A  form  of  amblyopia  has  been  described  bj-  Martin  and  called  astigmatic 
amblyopia,  dependent  upon  an  imperfect  development  of  the  functions  of  the  finer 
anatomic  elements  of  the  retina.  It  has  been  attributed  to  the  fact  that  at  the 
time  of  the  education  of  the  sense  of  sight,  owing  to  astigmatism  the  retina  has 
been  asymmetrically  stimulated,  and  consequent!}'  there  has  been  asymmetry  of 
visual  acuteness. 

35  545 


546    AMBLYOPIA,    AMAUROSIS,    AND    DISTURBANCES    OF   VISION 

discovered   (Heine,  Lohmann).     Leber's  tapeto-retinal  degeneration 
(page  515)  is  one  cause  of  congenital  blindness. 

Defective  vision,  attributed  to  lack  of  use  {amblyopia  ex  anopsia, 
argamblyopia,  according  to  Gould),  may  occur  on  account  of  obstruc- 
tion to  the  ra3's  of  light  falling  upon  the  retina — e.  g.,  congenital  corneal 
opacities,  congenital  cataract,  and  impervious  persisting  pupillary  mem- 
brane; or  in  an  eye  which  from  early  infancy  has  squinted,  and  has. 
therefore,  not  been  concerned  in  the  visual  act  (compare  with  page  598). 
The  amblyopia  of  a  squinting  eye  may  disappear  if  the  seeing  eye 
becomes  blind  or  is  removed;  a  number  of  such  cases  are  on  record. 

Gould  maintains  that  certain  cases  of  ambh'opia  which  have  been 
attributed  to  disuse  are  really  due  to  a  low  grade  of  choroidoretinitis 
affecting  the  macular  region,  brought  into  existence  by  an  irritating 
stimulus  with  which  a  long-continued  ametropia  has  supplied  this  area. 
It  is  probable  that  the  explanation  of  many  of  such  cases  depends 
upon  the  presence  of  types  of  macular  pigmentary  degeneration 
(pages  487  and  515). 

In  this  category  of  amblyopias  are  also  placed  certain  congenital 
defects  of  structure — e.  g.,  coloboma  of  the  iris  and  deficient  develop- 
ment of  the  entire  eye  (microphthalmos).  Retinal  hemorrhages  in  the 
newly  born  explain  some  cases.  Usually  one  eye  is  affected;  if  both 
are  amblyopic,  nj'stagmus  commonly  is  present.^ 

Congenital  Amblyopia  for  Colors  (Color-blindness). — Congenital 
disturbance  of  the  color-sense  has  been  found  in  about  3  per  cent,  of  the 
examinations  made  for  this  purpose,  but  it  is  extremely  rare  in  women 
(0.2  per  cent.).^  Both  eyes,  except  in  rare  instances,  are  affected,  and  a 
distinct  hereditary  tendency  has  been  noted  in  many  instances.  In 
other  respects  the  functions  of  eyes  which  are  "color-blind  "  are  normal, 
and  the  cause  of  the  condition  has  not  been  determined. 

The  methods  of  detecting  color-blindness  have  been  dcsc-ribed  on 
page  69.  Congenital  color-blindness  must  not  In'  confounded  with  the 
various  disturbances  of  the  color-sense  in  diseases  of  the  optic  nerve 
and  retina  or  in  hysteria. 

Derangements  of  the  perception  of  colors  have  been  divided  into 
two  varieties:  the  one  characterized  by  an  absence  of  the  power  to 
perceive  colors,  or  acliromatopsia;  and  the  other  characterized  by 
difficulty  in  distinguisiiing  colors,  or  dyschromatopsia.  The  former 
condition,  or  color-blindness,  is  rarely  total  as  a  congenital  defect  (a 
condition  which  is  not  uncommon  as  tiie  result  of  patliologic  clianges 
in  the  ojjtic  nerve,  etc.) ;  generally  it  is  partial — i.  e.,  one  or  nu)re  of  the 
fundamental  colors  are  not  recognized. 

According  to  Helmholtz's  theory,  three  classes  of  partial  color- 

'  A  persistent  fiaiiip  of  the  lid,  .siieli  as  occurs  in  eliililren,  uiin'lieveil  for  weeks 
at  a  time,  may  profluee  Miiidness,  noticed  when  the  eyes  are  finally  opened,  tem- 
porary in  its  character,  with  norm.-d  ophthnlmoscopic  :ii)pearniices.  In  other  c;tses 
the  lo.ss  of  vision,  however,  is  permanent,  with  nros.s  changes  in  the  eye-ground. 
This  condition  has  l>een  r«'f»'rred  to  umh'r  Mleph.nrospa.sm  (p.'ine  1S9). 

'■' For  a  study  of  "Color  Hlind  Females  ;ind  the  Inheritance  of  Color  HIindness 
in  Man"  hy  In^olf  Schiotz,  .see  liriti^h  .lournal  of  Ophthalmolony,  .\un.,  1".'20. 


CONGENITAL   AMBLYOPIA    FOR    COLORS  547 

blindness  exist — blue-blindness   (also  called  violet-blindness),   green- 
blindness,  and  red-blindness. 

A  person  afflicted  with  hlue-blindness  {yellow-blue  blmdness,  accord- 
ing to  Hering)  sees  only  red  and  green.  He  usually  confounds  blue 
with  green,  purple  with  red,  orange  with  yellow,  and  violet  with  yellow- 
green  or  gray. 

A  person  afflicted  with  green-blindness  {red-green  blindness,  accord- 
ing to  Hering),  to  quote  from  Thomson,  confounds  light  green  with 
dark  red,  does  not  recognize  a  dark-green  letter  on  black,  but  recognizes 
well  a  red  one  on  the  same  background.  Preyer  states  that  the  most 
frequent  confusions  are:  brown  with  dark  green,  red  with  green,  red 
with  orange,  red  with  yellow,  red-yellow  with  green-yellow,  bluish- 
green  with  purple. 

A  person  afflicted  with  red-blindness  {red-green  blindness,  according 
to  Hering),  again  to  quote  from  Thomson,  confounds  light-red  colors 
with  dark  green,  and  cannot  see  a  dark-red  square  on  a  black  ground. 
According  to  Preyer,  the  most  frequent  confusions  are:  red  with  dark 
green,  yellow  with  green,  green  with  bright  red,  bluish  green  with  gray, 
orange  with  greenish  yellow  or  with  red,  orange  with  golden  yellow, 
with  grass  green,  or  with  red,  purple  with  blue. 

Red-  and  green-blindness  are  the  most  usual  manifestations  of 
color-blindness;  it  is  often  hereditary;  the  other  type — blue-blindness 
— is  not  common.  According  to  Lohmann,  records  concerning  the 
hereditary  factors  in  blue-yellow  blindness  are  wanting.  Knies  has 
described  congenital  violet-blindness;  red  and  purple  are  not  distin- 
guished from  each  other,  both  being  called  red. 

In  the  second  variety,  or  imperfection  in  the  color-sense  (reduced 
color-sense),  the  individual  may  correctly  recognize  brightly  marked 
colors,  but  confuses  colors  which  are  closely  allied  and  the  various 
shades.  To  him  violet  and  blue  and  orange  and  red  are  difficult  dis- 
tinctions. Dyschromatopsia  should  be  distinguished  from  partial 
color-blindness  (Landolt) . 

The  theory  of  color  vision  has  been  the  subject  of  much  speculation, 
and  many  theories  have  been  advanced  but  none  of  them  is  entirely 
satisfactory.  Two  will  be  mentioned.  The  Young- Helmholtz  theory 
assumes  the  existence  in  the  retina  of  three  kinds  of  end-organs,  each 
w^ith  its  own  photochemical  substance,  which  can  be  decomposed  by  a 
certain  color;  that  is,  there  is  a  red-sensitive  substance,  a  green-sensi- 
tive substance,  and  a  blue-sensitive  substance.  If  a  light  mainly 
stimulates  the  red-,  green-,  or  blue-sensitive  substance  it  gives  rise  to 
the  sensation,  respectively,  of  red,  green,  and  blue,  while  simultaneous 
stimulation  of  two  or  more  of  these  substances  gives  rise  to  other  color- 
sensations,  including  white  light.  A  color-blind  person,  according  to 
this  theory,  is  one  in  whom  two  of  these  substances  have  a  like  com- 
position. The  Hering  theory  assumes  the  existence  in  the  retina  of  a 
white-black,  red-green,  and  yellow-blue  visual  substance,  which  may 
be  either  decomposed  (disassimilated)  or  restored  (assimilated)  by 
the  light.     A  destructive  process,  or  one  of  disassimilation,  in  the  white- 


548    AMBLYOPIA,    AMAUROSIS,    AND    DISTURBANCES    OF  VISION 

black  substance  by  white  light  or  any  other  simple  or  mixed  color,  pro- 
duces a  sensation  of  white;  a  process  of  restitution,  or  (msimilation,  in 
this  substance  produces  the  sensation  of  l)lack.  Red  light  produces 
disassimilation  in  the  red-green  substance,  and  thus  the  sensation  of 
red;  green  light  causes  a  process  of  restitution,  or  assimilation,  in  the 
red-green  substance,  and  thus  the  sensation  of  green.  From  decom- 
position of  the  yellow-blue  substance  by  yellow  light  arises  the  sensa- 
tion of  yellow,  while  the  sensation  of  blue  is  produced  by  a  process  of 
assimilation  in  the  same  substance.  A  color-blind  person,  according  to 
this  theory,  is  one  in  whoso  retina  the  red-greenorblue-yellowsubstance 
is  absent.^ 

Treatment  is  ordinarily  unavailing,  but  recent  investigations  indi- 
cate that  if  the  defect  is  ascertained  early  enough  systematic  training 
may  succeed  in  developing  the  deficient  color-sense;  hence  the  impor- 
tance of  the  examination  of  the  color-sense  in  young  children. 

Congenital  Total  CoIor=bIindness. — This  rare  affection  has 
been  particularly  well  studied  by  Grunert  and  I'hthoff.  To  those 
affected  (twice  as  many  males  as  females)  colors  appear  only  as  impres- 
sions of  light  and  dark.  According  to  Grunert,  the  colors  at  the  red 
end  of  the  spectrum  seem  lighter  than  to  the  normal  eye,  while  those  at 
the  violet  end  seem  darker.  Total  color-blindness  is  nearly  always 
associated  with  defective  central  vision,  nystagmus,  and  photophobia. 
The  eye-ground  may  be  normal;  or  there  may  be  pallor  of  the  disk  and 
macular  changes.  A  central  scotoma  is  common.  The  eyes  are  more 
frequently  mj'opic  than  hyperopic.  Several  members  of  the  same 
family  may  be  affected,  and  in  some  instances  consanguinity  of  the 
parents  has  been  determined. 

Congenital  Word=blindness. — In  this  condition  the  memory  for 
the  optic  impression  of  words  and  letters  is  greatly  deficient  or  wanting. 
The  affection  is  more  frequent  in  boys  than  in  girls,  although  girls  are 
by  no  means  exempt,  as  has  sometimes  l)oen  stated.  As  C.  J.  Thomas 
points  out,  it  may  assume  a  family  type,  and  in  a  number  of  instances 
more  than  one  member  of  a  family  has  suffered.  Examination  reveals 
normal  eyes,  good  vision  after  any  refractive  errors  have  been  cor- 
rected, and  either  inabilitj^  to  learn  to  spell  and  to  read,  or  else  great 
difhculty  in  these  respects.  Sometimes  figures  are  more  readily 
recognized  than  letters.  In  other  respects  the  subjects  of  this  affection 
are  normal  and  other  forms  of  memory  are  good,  indeed,  not  infre- 
quentl}^  the  auditory  memory  is  more  develop(»d  than  in  a  normal  child. 
The  condition  is  jjrobably  (hie  to  a  congiMiital  defect   in  the  visual 

*  Miiny  ol)j('ction.s  to  tlic  Younn-lIi-liiiliDltz  aiul  IleiiiiK  llicorios  Imvo  boon 
roconlod  and  \>y  koiiio  writers  tliov  arc  entirely  rejected.  Otlier  tlieorios  have  heon 
propounded  notal)ly  one  l)y  Dr.  Kdridne-CJreen.  It  i.s  not  possil)l(>  in  a  l>ook 
of  this  scope  to  inchide  them  or  to  attenij)t  an  analysis  of  the  sul)ject.  Those 
interested  should  consult  "  Introduction  to  the  Study  of  Color-vision"  by  J.  llerhort 
Parsons;  "Coior-lilindness  and  ("olor-sense  "  and  "Theories  of  Color-vision"  in  the 
American  l'!ncyclo|)edia  of  <  )|)hthalmolony,  Vol.  IV,  l"tl4,  and  "Color  Mlindnesa." 
2nd  Isdition,  l)y  luiridKe-dreen,  also  "The  IMiysiolo^y  of  Vision"  hy  the  same 
author. 


TKAUMATIC    AMBLYOPIA  549 

memory  center  for  words  and  letters.  As  Hinshelwood  (to  whom  we 
are  particular!}^  indebted  for  early  studies  of  this  affection)  and  all 
those  who  have  written  on  the  subject  since  insist,  great  care  should 
be  exercised  to  detect  this  affection  early  in  life,  because  it  is  much 
more  common  than  is  generally  supposed.  Its  frequency  is  greater, 
in  all  probability,  among  the  lower  classes.  Much  can  be  done  by 
systematic  training — for  example,  with  block  letters — as  Hinshelwood 
suggests,  so  that  the  child  may  assist  the  visual  memory  by  the  sense 
of  touch.  C.  J.  Thomas,  discussing  the  treatment  of  this  affection, 
suggests  the  phonic  method  as  a  suitable  one  to  "employ,  because  in  it, 
at  first  at  least,  the  visual  word-images  are  ignored. 

Reflex  Amblyopia. — Certain  cases  of  partial  or  complete  loss  of 
vision  have  been  vaguely  attributed  to  irritations  in  distant  portions  of 
the  body — for  instance,  the  presence  of  parasites  in  the  intestinal  canal. 
In  many  of  these  instances,  however,  a  proper  investigation  has  shown 
that  other  causes  have  been  active  in  producing  the  defective  sight. 

A  number  of  cases  are  on  record  in  which  an  irritation  through  the 
branches  of  the  fifth  nerve  has  been  supposed  to  produce  an  amblyopia, 
chiefly  with  disease  of  the  teeth.  At  all  events,  in  any  case  of  ambly- 
opia unattended  with  ophthalmoscopic  changes,  and  not  readily 
classified  in  any  of  the  well-recognized  groups,  a  thorough  examination 
of  the  teeth  is  advisable. 

Traumatic  Amblyopia. — This  may  occur  after  severe  injuries  of 
the  head,  especially  in  the  occipital  region  and  the  region  of  the  external 
angular  process  of  the  frontal  bone;  bruises  along  the  course  of  the 
spinal  cord  after  a  railroad  injury;  and  blows  upon  the  brow  in  the 
region  of  the  supra-orbital  nerve. 

In  some  of  the  cases  there  is  a  fracture  across  the  optic  canal,  a 
hemorrhage  into  the  intracranial  cavity,  or  some  disorganization  of  the 
brain-contents,  followed  by  secondary  changes  in  the  optic  nerve. 
(See  also  page  541.)  In  other  instances  no  ophthalmoscopic  changes 
are  discovered,  and  the  defective  vision  may  be  temporary  in  char- 
acter, or  there  may  be  effusion  or  hemorrhage  into  the  intersbeath 
of  the  optic  nerve,  edema  of  the  retina,  and  neuritis.  Heinorrhage 
into  the  sheath  of  the  optic  nerve  after  fracture  or  traumatism  of  the 
skull  has  been  observed  a  number  of  times  and  has  been  especially 
well  studied  by  Uhthoff.  In  a  specimen  examined  by  the  author 
and  T.  B.  Holloway  the  sheaths  were  fully  distended  with  blood 
and  there  were  also  many  retinal  hemorrhages.  An  extensive  fracture 
of  the  base  of  the  skull  had  occurred  and  had  caused  this  hematoma  of 
the  optic  nerve-sheath.  Hemorrhage  into  the  sheath  of  the  optic  nerve 
may  have  its  source  in  an  intracranial  hemorrhage,  for  instance  rup- 
ture of  an  aneurysm  (F.  H.  Doubler  and  S.  B.  Marlow).  Hematoma 
of  the  optic  nerve  sheath  was  frequently  observed  during  the  past  war 
following  cranial  and  orbital  injuries.  In  these  cases  peripapillary 
hemorrhage  was  comparatively  rare,  but  a  peripapillary  brown  ring  due 
to  hemic  pigment  was  often  observed.  Atrophy  of  the  optic  nerve 
was  the  usual  result. 


550    AMBLYOPIA,    AMAUROSIS,    AND    DISTURBANCES    OF  VISION 

Amblyopia  after  railroad  injuries  is  often  exaggerated  by  patients 
in  the  hope  of  securing  damages. 

During  the  recent  war  many  soldiers  developed  in  unusual  degree 
a  variety  of  nervous  phenomena  attributed  to  the  concussions  re- 
sulting from  exploding  shells,  and  the  term  ''  shell-ahock"  came  into 
existence.  The  majority  of  these  cases  were  the  result  of  a  true 
neurosis  which  was  neither  conscious  nor  voluntary.  Amblyopia 
was  a  common  manifestation  and  varied  in  degrees  from  a  reduction 
of  vision  which  was  described  as  ''foggy"  to  complete  blindness  which 
was  sometiihes  transitory,  or  short-enduring  (several  weeks)  or  long- 
enduring  (months  or  even  a  year  or  more). 


Fig.  239. — Hematoma  of  optic  ncrve-.shcath.     (Patient  in  the  University  Hospital.) 

In  general  terms,  the  evolution  of  psychic  blindness  after  a  soldier 
was  "shell-shocked"  was  as  follows:  During  tlie  period  of  being  semi- 
conscious, or  dazed,  he  was  partly  or  (entirely  l)lin(l;  vision  often  re- 
turned with  the  restoration  of  consciousness,  or  amblyopia  persisted  for 
varying  periods  of  time,  if  the  soldier's  attention  was  fixtMl  u]ion.  or  di- 
rected to.  his  eyes.  By  a  process  of  auto-suggestion  the  loss  of  vision 
was  perpetualcd.  Associated  with  this  jisychic  or  hysteric  cecity,  there 
often  was  tonic  blei)harospasm,  that  is,  a  convulsive  closun*  of  the 
lids,  or  clonic  blepharosjiasm,  that  is,  continued  blinking  of  the  lids, 
sometimes  designated  "fluttering"  or  "twinkling"  of  the  lids.  The 
pujjils  reacted  normally;  the  eye  grounds  wer(>  normal.  The  iields  of 
vision,  if  it  was  jjossibh'  to  chart  them,  were  variously  contracted 
(see  page  55G).  The  icstoration  of  vision  was  sometimes  jnompt; 
sometimes  very  delibeiat.e.  The  "shooting  eye"  was  often  the  last 
to  iccover. 


J 


GLYCOSURIC   AMBLYOPIA  551 

The  usual  measures  suited  to  the  treatment  of  neurotics,  sugges- 
tion, etc.,  were  effective. 

In  a  certain  number  of  these  cases  of  amblyopia  following  shell  con- 
cussions the  blindness  depended  upon  an  organic  basis,  that  is,  com- 
motio retinae,  rupture  of  the  choroid,  intracranial  lesions — a  class  very 
different  from  the  one  just  described. 

Amblyopia  and  amaurosis  occur  under  the  influence  of  disease  and 
the  toxic  action  of  certain  drugs,  due  either  to  a  direct  effect  upon  the 
retinae  and  optic  nerve,  to  an  influence  upon  the  visual  centers,  or  to 
some  change,  perhaps  of  vasomotor  origin,  affecting  the  blood-supply 
of  these  structures. 

In  this  category  may  be  noticed: 

1.  Uremic  Amblyopia,  or  Amaurosis. — This  may  occur  in  any 
form  of  renal  disease,  but  is  more  common  in  the  acute  nephritis  of  the 
eruptive  fevers,  especially  scarlet  fever,  and  of  pregnancy  than  in  other 
varieties  of  kidney  affections.  In  scarlet  fever  it  appears  with  albu- 
minuria in  the  stage  of  desquamation,  and  is  bilateral,  the  blindness  in 
many  cases  being  absolute  and  often  associated  with  brain  symptoms : 
convulsions,  vomiting,  stupor,  coma,  and  hemiplegia.  In  spite  of  the 
blindness,  the  preservation  of  the  pupillary  reactions  is  the  rule;  some- 
times the  pupils  are  dilated  and  motionless. 

The  ophthalmoscope  picture  may  be  negative,  or  there  is  a  slight 
neuritis,  a  little  woolliness  of  the  surface  of  the  optic  disk  or  delicate 
edema  of  the  retina.  A  functional  amblyopia  during  pregnancy  has 
been  noted,  that  is  one  without  the  presence  of  albuminuria,  perhaps 
due  to  toxemia  or  circulatory  disturbances.  The  prognosis,  as  far 
as  vision  is  concerned,  is  good. 

The  treatment  does  not  differ  from  that  which  is  applicable  to  the 
disease  which  produced  it. 

2.  Qlycosuric  Amblyopia.^ — In  addition  to  the  affections  of  vis- 
ion already  described  in  connection  with  diabetes  (paresis  of  accom- 
modation, premature  presbyopia,  alterations  in  refraction,  cataract, 
and  retinal  hemorrhages),  there  occurs  an  amblyopia  in  this  disease 
an  which  the  visual  field  is  sometimes  peripherally  intact,  sometimes 
peripherally  restricted,;  and  occasionally  hemianopic,  but  in  which 
there  is  a  central  color  scotoma.  Ronne  ascribes  diabetic  amblyopia 
not  to  an  interstitial  neuritis,  but  to  a  process  of  degeneration.  This 
amblyopia  may  be  the  onlj^  sj'mptom  of  diabetes,  and  in  any  unex- 
plained case  of  amblj'opia  the  urine  should  be  examined  for  sugar,  a 
practice  which  is  necessary  if  color  scotomas  are  found,  even  if  the 
history  of  the  abuse  of  tobacco  is  obtainable.  It  has  seemed  to  the 
author  that  so-called  glj^cosuric  amblyopia  is  more  apt  to  be  found 
in  diabetics  who  use  tobacco  freel}^  than  in  those  who  are  abstainers 
in  this  regard.  It  is  a  clinical  fact  that  diabetic  retinitis  (see  page 
478)  is  not  common  among  the  subjects  of  glycosuria  unless  there  is 
an  associated  anteriosclerosis  or  nephritis.  Recently  interesting  ob- 
servations in  this  respect  have  been  reported  from  the  Mayo  Foun- 
dation (H.  P.  Wagener  and  R.  M,  Wilder).     It  is  probable  that  in 


552    AMBLYOPIA,    AMAUROSIS,    AND    DISTURBANCES    OF   VISION 

glycosuric  amblyopia  and  retinitis,  at  least  in  a  good  many  of  the 
cases,  the  metabolic  disturbances  are  not  the  primary  cause  of  the 
ocular  affection. 

The  prognosis  is  unfavorable,  and  the  treatment,  which  should  in- 
clude the  usual  measuri's  suited  to  dialx'tics,  is  not  very  efhcacious. 

3.  Malarial  Amblyopia. — In  addition  to  amblyopia  in  malarial 
cachexia  with  lesions  apparent  in  the  fundus,  are  those  cases,  without 
such  lesions,  due  to  a  special  action  of  the  malarial  poison  upon  the 
optic  nerve  and  the  retina.  There  is  transient  loss  of  vision,  or  com- 
plete blindness,  lasting  from  several  hours  to  some  days  or  even 
months.  In  most  of  the  instances  ophthalmoscopic  findings  are 
negative,  or  the  descriptions  are  couched  in  vague  terms  applied  to 
the  retina  and  optic  nerve — "congestion,"  "hyperemia,"  and  ''redder 
than  normal."     The  affection  may  be  unilateral  or  bilateral. 

4.  Amblyopia  from  Loss  of  Blood. — Loss  of  sight  often  follows 
hemorrhage,  more  frecjuently  if  this  is  spontaneous  than  if  it  is  trau- 
matic, and  is  said  to  be  most  complete  after  hemorrhage  from  the 
stomach.  It  also  may  follow  cpistaxis,  hemoptysis,  urethral,  uterine 
and  intestinal  hemorrhage. 

Two  very  different  results  may  ensue:  Either  a  temporary  blindness, 
owing  to  the  impoverished  blood-supply  of  the  visual  centers  or  retina, 
or  a  permanent  loss  of  sight  and  atrophy  of  the  optic  nerve.  Ward 
Holden  has  shown  that  the  amblyopia  following  hemorrhage  is 
due  to  degeneration  of  the  retinal  ganglion-cells,  together  with 
their  long  processes,  which  make  up  the  centripetal  fibers  of  the  optic 
nerve. 

The  ophthalmoscopic  appearances  vary  from  a  slight  pallor  to  com- 
plete atrophic  whiteness  of  the  papilla,  with  contraction  of  the  arteries. 
The  lesions  in  the  unfavorable  cases  usuallj'^  do  not  appear  until  a  week 
or  more  after  the  hemorrhage  has  taken  place.  Optic  neuritis  and 
hemorrhages  into  the  retina  may  also  arise.  Occasionally,  the  papilla 
is  highly  edematous,  suggesting  in  ai)i)earance  a  small  white  mound; 
the  so-called  "pallid  edema  of  the  disk."  In  a  patient  recently  under 
the  author's  care,  this  phenomenon  was  most  marked,  the  swelling 
attaining  a  height  of  about  5  D.  Hemorrhages  following  criminal 
abortion  was  the  cause;  blindness  was  teniporaiily  practically  com- 
plete; partial  restoration  of  vision  occuired.  Tlu'  piognosis  is  most 
favorable  in  uterine  cases. 

The  treatment  consists  in  the  use  of  iron,  arsenic,  and  stryihniii, 
complet(!  rest,  and  an  easily  assimilated  diet .  Intravenous  saline  iiijei'- 
tions  are  also  reconuneiided  as  remedial  agents  l,l']lschnig).' 

Amblyopia  from  the  Abuse  of  DruKS. — A  certain  number  of 
toxic  agents  (lead,  tobacco,  alcohol,  etc.)  proiiuce  an  axial  neuritis  or  a 
degeneration  and  destruction  of  the  n^tinal  ganglion-cells,  witii  great 

'  Sudden  tjliiitiiifss  witli  preserved  pupillary  reaction  and  witliout  ophthal- 
moscopic chanKt'S  ha.s  ln'i'ii  noted  in  whoopiiin-foiinh,  and  is  probably  (hie  to  odonia 
lu'twccn  llu!  (•orj)ora  (piiidii^cniina  anil  occipital  lohts.  Sudilcn  hliiidiioss  in  old 
persons  with  arteriosclerosis  has  Itccn  uh.scrvfd  (I'hlholT). 


QUINIX    AMAUROSIS  553 

loss  of  vision,  and  these  have  been  described  under  the  general  term 
orbital  optic  neuritis  (see  page  537). 

Amblyopia,  more  or  less  complete,  msiy  also  arise  under  the  toxic 
influence  of  nitrate  of  silver,  chlorate  of  potassium,  mercury,  arsenic, 
atoxyl,  bisulphid  of  carbon,  nitrobenzol,  salicylic  acid,  oil  of  winter- 
green,  cannabis  indica,  coffee,  tea,  stramonium,  male  fern,  iodoform, 
osmic  acid,  chloral,  antipyrin,  and  lead.  The  last  agent  may  produce 
a  neuritis,  but  also  an  amblyopia  without  ophthalmoscopic  changes. 
It  is  usually  transient,  occurs  in  acute  cases,  and  has  been  compared  by 
Gowers  to  the  temporary  amaurosis  of  uremia. 

Some  of  these  toxic  agents  may  cause,  in  addition  to  the  loss  of 
vision,  a  central  scotoma — for  example,  bisulphid  of  carbon,  stramo- 
nium, and  iodoform;  complete  blindness  and  atrophj-  of  the  optic  nerve 
may  be  the  result  of  the  action  of  others — for  instance,  male  fern 
and  iodoform.  Dinitrotoluene-amblyopia  may  occur  among  munition 
workers  and  amblyopia  is  also  due  to  nitrophenol.  Associated  con- 
ditions are  peripheral  neuritis. 

The  loss  of  vision  which  occurs  under  the  influence  of  four  sub- 
stances— quinin,  ethj-lhydrocuprein  methyl-alcohol,  and  atoxyl — de- 
serves special  mention. 

Quinin  Amaurosis. — Although  in  most  instances  quinin  amblyo- 
pia, or  amaurosis,  follows  the  ingestion  of  a  large  quantity  of  the  drug, 
occasionally  the  symptoms  are  caused  by  moderate  doses.  The 
author  has  seen  12  grains  (0.78  gm.)  produce  decided  temporary 
amblyopia  in  a  susceptible  and  neurotic  woman. 

The  characteristic  chnical  features  of  quinin  amaurosis  are  total 
bhndness  subsequent  to  taking  large  doses  of  the  drug,  extreme  pallor 
of  the  optic  disks,  marked  diminution  of  the  retinal  blood-vessels  in 
number  and  cahber,  and  contraction  of  the  field  of  vision.  Other 
symptoms  which  have  been  noted  are:  diminution  of  the  color-  and 
light-sense,  dilated  pupils,  and  immobile  iris  during  the  blind  stage,  and 
occasionally  anesthesia  of  the  cornea.  Usually  the  effect  of  quinin 
upon  the  ear  is  manifested  by  deafness  and  tinnitus. 

The  restoration  of  central  vision  may  be  perfect  or  incomplete. 
The  contracted  field  of  vision  gradually  widens  out,  but  does  not  regain 
its  normal  limits.  The  disk  may  remain  paUid  and  quite  atrophic 
in  appearance,  years  after  the  poisoning;  in  other  instances  it  resumes 
its  normal  tint,  but,  usually  the  contracted  vessels  do  not  regain  their 
proper  caliber.  Reduction  of  light-sense  is  a  permanent  feature.  In 
one  case  (Gruening)  a  cherry-colored  spot  was  noted  in  the  macula, 
in  another  a  scotoma  in  the  visual  field.  Occasionally  the  bhndness 
is  permanent. 

The  bhndness  following  the  administration  of  toxic  doses  of  ethyl- 
hj^drocuprein  (optocliin),  especially  in  the  treatment  of  pneumonia, 
resembles  in  all  respects  that  of  quinin  ambh'opia. 

The  first  effect  of  the  toxic  influence  of  quinin  is  to  lessen  the  blood- 
supply  of  the  retina  and  optic  nerve,  and  later,  as  the  author  has 
experimentally  shown  in  dogs,  permanent  optic-nerve  atrophy  ensues. 


5.54    A\rBLYOPIA,    AMAUROSIS,    AND    DISTURBANCES    OF   VISION 

Ward  Holden  has  demonstrated,  and  his  results  have  been  fully  con- 
firmed by  Drualt,  Birch-Hirschfeld,  and  a  number  of  other  observers, 
that  the  blindness  is  due  to  a  degeneration  of  the  ganglion-cells  and 
nerve-fibers  of  the  retina,  followed  by  an  ascending  degeneration  of  the 
optic  nerve.  Anatomic  examination  of  eye  blinded  by  optochin 
reveals  degeneration  of  the  ganglion  cells,  vascular  change  and  partial 
atrophy  of  the  disk  (G.  Abelsdorff).^ 

The  treatment,  in  addition  to  the  discontinuance  of  the  drug,  consists 
in  the  administration  of  nitrite  of  amyl,  which  will  cause  temporary 
improvement  in  vision,  and  of  the  exhibition  of  strychnin  and  digitaUs, 

Methyl=alcohol    Blindness,   or  Amaurosis. — The   amount   of 
wood-alcohol  which  may  cause  blindness  represents  a  varying  quantity. 
Thus,  bUndness  and  atrophy  of  the  disk  have  followed  the  ingestion  of 
2  to  5  drams  (7.8-19.4  gm.),  while  recovery  after  drinking  3-^  pint  (236 
c.c.)  of  this  liquor  has  been  observed  (INIoulton).     In  short,  methyl- 
alcohol  intoxication  is  an  example  of  idiosyncrasy  (F.  Buller,  C.  A. 
Wood).     The  number  of  immune  persons,  however,  cannot  be  great. 
Methyl-alcohol  itself,  Columbian  spirits,  other  varieties  of  purified 
wood-alcohol,  and  the  drug  in  the  form  of  an  adulterant  for  ethyl-alcohol 
in  cheap  whiskies  and  other  alcoholic  beverages,  as  well  as  in  Jamaica 
ginger,  certain  essences,  bay-rum,  cologne  water,  etc.,  are  capable  of 
producing  the  most  violent  general  toxemia  and  visual  disturbance. 
Igersheimer  bcheves  the  influence  of  methyl-alcohol  depends  upon  the 
admixture  of  fusel  oil.     Briefly,  the  symptoms  are  these :  Intense  gastro- 
intestinal disturbance  if  the  dose  is  not  too  large,  followed,  if  it  is 
greater,  by  severe  headache,  giddiness,  and  coma;  rapid  failure  of 
sight,  which  may  improve,  but  soon  relapses;  contracted  visual  fields 
and  usuall}''  absolute  central  scotomas;  and,  finally,  total  or  nearly 
total  blindness.     Ophthalmoscopically,  there  have  been  noted  blurring 
of  the  edges  of  the  disk,  positive  neuritis  (rare),  and  complete  atrophy 
without  signs  of  preceding  inflammation.     In  many  instances  there  is 
diminution  in  the  size  of  the  retinal  vessels.     Occasionally,  there  is 
decided  pain  on  movement  of  the  eyes  or  on  pressing  them  backward 
into  the  orbit.     The  prognosis  of  methyl-alcohol  poisoning  is  most 
unfavorable.     A   number   of   fatal    cas(>s   have   been    reported.     Not 
onl}^  may  the  poison  enter  in  the  usual  manner  through  the  stomach, 
but  blindness  has  resulted  from  inhalation,  aided  by  absorption,  as  the 
author  has  shown,  through  the  cutaneous  surface.     A  few  examples  of 
restoration  to  nearly  normal  vision  have  been  reported.     The  blhulness 
d(!pends,  as  Holden  and  liirch-liirschfeld  have  demonstrated,  upon 
nutritive  changes  in  the  ganglion-cells  of  the  retina.     It  is  possil)le 
that  there  may  be  a  simultaneous  action  on  the  ganglion-cells  and  the 
tissues  of  the  optic  nerve  (GitTord).     The  treatment  of  this  form  of 
amaurosis  includes  in  the  early  stages  j^ilocaipiii  and  pc^tassiuin  iodid, 
later  strychnin  hypoderniically  and  !>>■  t  he  iimul  h  correcl  ion  of  ;icidosis 
and  galvanism  are  inijjortant  (ZieglerJ. 

'  'I'lic  inoHt  recent  imd  coinplt'tp  rt'view  of  iill  of  tlie  iiiMiiifesf .'itimis  of  (|uiniii 
lilimliicss  is  liy  i{.  II.  lUliot,  see  Aiiiericim  .Ioiirii!tl  of  Oplitluiliuolony,  .S'ptemluT, 
lUlS. 


HYSTERIC  VISUAL   DISTURBANCES  555 

Arsenic  Amblyopia. — Atoxyl  has  been  much  employed  in  the  treat- 
ment of  various  conditions,  notably  certain  skin  diseases,  chlorosis,  sj'ph- 
ilis,  and  trypanosomiasis.  Serious  visual  disturbances  have  followed 
its  use  in  a  number  of  instances.  The  following  have  been  reported: 
Reduction  of  visual  acuteness  from  one-half  to  complete  blind- 
ness; contraction  of  the  visual  field,  especialh'  on  the  nasal  side;  pallor 
and  atrophy  of  the  optic  disk,  with  narrowing  of  the  retinal  vessels; 
usually  no  central  scotoma,  but  at  times  a  central  scotoma  for  colors 
and  sometimes  visual  hallucinations  and  colored  vision  (cyanopsia). 
In  one  patient  retinal  hemorrhages  were  found.  The  amount  of  the 
drug  which  has  produced  these  visual  disturbances  has  varied  con- 
siderabh"  1.2  grams,  given  subcutaneously  for  anemia,  wnthin  twenty- 
six  days  (Steinebach) ;  5.1  grams  within  twenty-six  days  (Lesser  and 
Greeff);  50  grams  within  seven  months  (von  Kriidener);  4.5  grams 
within  one  month  (Kopke) .  Koch  observed  a  number  of  cases  of  blind- 
ness without  ophthalmoscopic  change  after  injection  of  1  gram  of  atoxyl 
for  the  cure  of  sleeping-sickness.  The  blindness  has  been  ascribed  to 
optic-nerve  atrophy  with  primary  involvement  of  the  retina,  and  to 
retrobulbar  neuritis  and  consecutive  atrophy;  it  has  also  been  attributed 
to  central  lesions. 

BUndness  following  the  administration  of  other  arylarsonates,  for 
example,  soamin,  arsacetin,  hectin,  orsudan,  have  been  reported. 
The  harmful  action  is  due  to  the  anilin  in  these  compounds  and  not  to 
the  arsenic.  Amblyopia  due  to  inorganic  arsenic  compounds  presents 
features  entirely  different  from  those  which  the  organic  preparations 
produce  and  the  prognosis  is  good  (Schirmer).  The  arylarsonates 
cause  progressive  optic-nerve  atrophy.  It  has  been  suggested  that 
the  primary  action  of  the  drug  may  be  on  the  blood-vessels  (E.  T. 
Collins) .  The  harmful  dose  has  varied ;  much  depends  on  idiosyncrasy, 
Salvarsan  does  not  cause  blindness,  i.  e.,  it  has  no  poisonous  influence 
in  proper  dosage  on  the  healthy  optic  nerve. 

Hysteric  Visual  Disturbances  {Amblyopia,  Amaurosis,  Asthen- 
opia).— Hysteric  amaurosis  is  characterized  by  complete  abeyance  of 
the  visual  sensation.  It  occurs  both  as  a  unilateral  and  a  bilateral 
affection,  the  former  being  far  more  frequent  than  the  latter.  The 
subjects  of  this  condition  are  more  frequently  females  than  males. 
Occasionally,  the  blindness  lasts  but  a  very  brief  period  of  time,  and 
occurs  during  a  crisis;  at  other  times  it  lasts  for  weeks,  months,  and,  it 
is  said,  for  years.  The  eye-grounds  are  normal.  Usually  the  pupils 
react  to  the  influence  of  light.  Sometimes  only  a  feeble  contraction 
follows  the  hght  stimulus;  occasionally  the  pupils  are  dilated  and  in- 
sensitive to  light  (Kerneis).  Generally  it  is  possible  to  prove  by  ordi- 
nary prismatic,  stereoscopic,  and  other  tests  that  the  supposed  blind 
ej^e  really  sees.  The  exact  similarity  of  these  phenomena  and  those 
associated  with  war  neuroses  (so-called  shell-shock  blindness)  is 
evident  (see  page  550). 

In  place  of  amaurosis,  incomplete  anesthesia  of  the  visual  sense,  or 
hj'steric  amblyopia,  may  occur.     This  includes  reduction  of  visual 


556    AMBLYOPIA,    AMAUROSIS,    AND    DISTURBANCES    OF   VISION 

acuteness,  disturbances  of  the  visual  field  for  white  and  for  colors,  dis- 
chromatopsia,  and  achromatopsia.  The  visual  field  in  hysteria  is 
characterized  by  concentric  contraction,  which  is  evident  at  the 
beginning  of  the  examination,  and  is  not  produced  by  repeated  measure- 
ment (retinal  tire  field),  and  the  amount  of  reduction  varies  from  a 
slight  contraction  to  such  extreme  restriction  that  the  most  peripheral 
circle  is  just  bej'ond  the  fixing-point.  ,  Sometimes  the  field  has  a  tubular 
character — that  is,  the  contracted  visual  field  maintains  tlie  same  size, 
no  matter  at  what  distance  from  the  examined  eye  the  point  of  fixation 
is  placed.  Similar  reductions  take  place  in  the  field  for  colors.  A 
somewhat  characteristic  variation  is  that  the  red  field  is  the  last  to  be 
affected,  with  the  result  that  its  extent  may  exceed  that  of  blue,  and 
become  the  most  peripheral  of  the  color  circles.  Occasionally  it  is  the 
most  peripheral  circle  for  the  entire  field.  This  is  the  so-called  inversion 
of  the  color-field.  Sometimes  there  is  an  excessive  extent  of  the  color- 
circles.  A  rare  hysteric  phenomenon  is  central  scotoma;  zonular 
scotoma  and  the  so-called  oscillating  field  have  been  observed. 

The  visual  field  phenomena  in  hysteria  are,  according  to  Bal)inski, 
due  to  suggestion.  If  suggestion  can  be  eliminated  they  do  not  de- 
velop. Morax,  at  first  impressed  as  most  observers  were,  with  the 
significance  of  the  retracted  field  of  vision  in  hysteria,  has  atiopted 
Babinski's  views.  Believing  that  it  is  impossible  to  avoid  suggestion 
during  ordinary  perimetric  examinations,  he  relies  upon  simpler 
methods,  taking  the  field  with  the  aid  of  outstretched  fingers  or  other 
familiar  objects.  Hurst  and  Symns  as  the  result  of  their  studies  on 
war  neuroses  reach  the  same  conclusion. 

In  the  light  of  our  present-day  knowledge,  there  is  no  question  that 
too  great  stress  has  been  laid  on  concentric  contraction  of  the  visual 
field  and  inversion  of  the  color  lines  as  a  stigma  of  hysteria.  None 
the  less  these  examinations  are  interesting  and  valuable  in  the  stud}' 
of  such  cases  from  the  very  fact  that  they  demonstrate,  or  help  to 
demonstrate,  the  presence  of  the  abnormal  nervous  mechanism  of 
highly  suggestible  patients. 

It  should  be  remembered  that  inversion  of  the  color-fields  is  not  | 

peculiar  to  hysteria;  it  has  been  observed  in  brain  tumor,  ataxia, 
hemorrhage  in  the  brain,  and  in  certain  toxemias,  notably  those  pro- 
duced by  lead  and  nitrobenzol.  Crossed  aviblyopia — that  is,  complete 
or  partial  blindness  on  the  same  side  as  the  hemianesthesia,  ami  as- 
sociated with  some  deficiency  of  acuteness  of  vision  upon  the  opposite 
side— is  sometimes  an  hysteric  manifestation,  llciiiianopsia  in  an 
enduring  form  is  never  due  to  hysteria.  As  a  temporary  visual-lield 
phenomenon  it  has  been  observed. 

Hysteria  produces  many  other  functional  disturbances  of  the  eye — 
monocular  diplopia,  ptosis,  blepliarospasm,  conjugat(>  deviation  of  the 
eyes,  and  th(!  great  symjjtom-gidup  gatheicd  under  the  term  "ictinal 
asthenopia"  (see  page  102). 

The  prognosis  of  these  cases  in  the  UKiiii  is  gooil.  :dl hough  the  l)hn(l- 
ness  tiiMV  last  for  long  |)erio(ls  of  tiiiu'. 


PRETENDED  AMBLYOPIA-  557 

The  treatment  consists  of  measures  calculated  to  improve  the  condi- 
tion of  the  patient — massage,  rest,  electricity,  and  tonics.  Usually  a 
cure  can  be  secured  by  suggestion. 

Pretended  Amblyopia  {Malingering). — For  the  purpose  of  escap- 
ing irksome  duties — for  example,  in  the  army — or  to  excite  sj^mpathy 
patients  will  occasionally  pretend  to  be  blind  in  one  eye.  In  order  to 
detect  the  deception  many  plans  have  been  originated.  Three  methods 
will  be  described: 

1.  The  Diplopia  Test. — This  is  performed  in  the  same  manner  as 
the  ordinary  examinations  of  the  exterior  ocular  muscles  with  prisms. 
The  subject  is  seated  before  a  lighted  candle  at  20  feet  distance,  and  a 
7°  prism  placed  before  the  admittedly  sound  eye.  If,  now,  superim- 
posed double  images  are  acknowledged,  there  is  binocular  vision,  and 
the  fraud  is  detected.  The  examiner  may  vary  the  test  by  placing  the 
prism  before  the  supposed  blind  eye,  either  base  up  or  base  down.  A 
prism  of  10°  base  outward  may  be  placed  before  the  eye  for  which 
bhndness  is  claimed.  If  this  eye  sees,  double  vision  will  be  produced 
and  the  ej^e  will  move  inward  to  correct  it  and  fuse  the  two  images. 

2.  Harlan's  Test. — This  is  an  extremely  useful  and  simple  test, 
and  is  performed  as  follows:  Place  an  ordinary  trial-frame  upon  the 
subject's  face  and  put  before  the  admittedly  sound  eye  a  high  convex 
glass  (+  16  D),  and  before  the  eye  which  is  claimed  to  be  blind  a  plain 
glass  or  a  weak  concave  spheric  (—  25  D),  which  will  not  interfere  with 
vision.  If  letters  placed  at  a  distance  of  6  meters  are  read,  the  act 
of  reading  must  have  been  done  by  the  eye  which  was  claimed  to  be 
sightless,  inasmuch  as  vision  at  that  distance  with  the  other  eye  is  ex- 
cluded by  the  presence  of  the  high  convex  lens.  The  test  may  be  fur- 
ther elaborated  by  covering  the  pretended  blind  eye  and  requesting 
the  patient  to  read  the  letters;  if  he  is  unable  to  do  so,  the  fraud  is  at 
once  exposed. 

3.  Tests  with  Colored  Glasses  and  Letters. — These  are  numerous. 
The  method  generally  employed,  or  some  modification  of  it,  is  known 
as  Snellen's  method.  The  patient  is  required  to  look  at  alternate  red 
and  green  letters.  The  admittedly  sound  eye  is  covered  with  a  red- 
glass,  and  if  the  green  letters  are  read  evidence  of  fraud  is  present. 
Instead  of  a  red  glass,  a  green  glass  may  be  used,  through  which 
the  red  letters  will  be  invisible.  Ingenious  letters,  based  upon  the 
fact  that  red  upon  a  white  background  viewed  through  a  red  glass 
disappears,  and  viewed  through  a  green  glass  appears  black,  have 
been  designed.  Tests  with  stereoscopes  may  also  be  made  to  detect 
malingering. 

If  a  mahngerer  claims  to  be  bhnd  in  both  eyes,  these  tests  will  not 
avail,  and  he  can  be  detected  by  placing  a  careful  watch  over  him. 
The  fact  that  the  pupil  contracts  on  exposure  to  hght  does  not  prove 
that  there  is  sight  in  the  eye,  because,  as  Swanzy  pointed  out,  a  lesion 
in  the  center  of  vision,  or  in  the  com'se  of  the  fibers  connecting  this 
center  with  the  corpora  quadrigemina,  producing  absolute  blindness, 
would  still  permit  a  perfect  reaction  of  the  pupil  to  Ught.     Priestley 


558    AMBLYOPIA,    AMAUROSIS,    AND    DISTURBANCES    OF   VISION 

Smith  and  E.  Jackson  suggest  the  following  test  for  feigned  binocular 
blindness.  Place  a  lighted  candle  in  front  of  the  subject ;  now  hold  a  6" 
prism,  base  out,  before  one  eye;  if  both  eyes  see,  the  one  behind  the 
prism  will  move  inward,  and  on  removing  the  prism  will  move  outward, 
the  other  oyo  remaining  fixed. 

Night=blindness  {Functional  Night-blindness;  often  incorrectly 
termed  Ilemeralopia,  but  properly  Nyctalopia). — It  has  already  been 
pointed  out  that  night-blindness  is  one  of  the  earlj-^  sj-mptoms  of  pig- 
mentary degeneration  of  the  retina.  In  the  present  condition,  how- 
ever, there  are  no  retinal  lesions. 

It  is  a  functional  defect  of  the  retinal  apparatus  concerned  with 
dark  adaptation  (Trcitel,  Birch-Hirschfeld)  which  may  be  and  often 
is  congenital.  Determining  causes  are  exposure  of  the  e3'e  to  strong 
light  and  glare,  together  with  a  debilitated  and  often  scorbutic  state 
of  the  system,  defective  nutrition,  autotoxemia,  etc.  Other  causes  are 
diet  deficient  in  fat  and  albumin,  disease  of  the  liver,  malaria,  and 
alcoholism.  It  affects  residents  in  tropical  countries,  often  soldiers 
and  sailors,  and  has  been  occasionally  observed  in  large  schools,  usu- 
ally in  the  early  spring  or  summer  (Nettleship,  Snell).  It  has  been 
reported  as  an  endemic  in  certain  countries,  especially  in  Russia  during 
the  Lenten  fasts. 

During  the  past  war  numerous  cases  of  night-blindness  were  dis- 
covered in  which  the  determining  causes  already  named  were  operative; 
also  great  fatigue,  loss  of  blood,  refractive  error,  especially  myopia  and 
astigmatism.  Not  infrequently  a  history  of  previous  defective  night 
vision  was  obtained;  often  the  eye  grounds  were  normal.  Sometimes 
they  showed  defective  pigmentation.  The  visual  symptoms  were 
those  which  have  been  recorded,  especially  reduction  of  vision  in 
diminished  light  and  constricted  visual  fields,  particularly  for  blue. 
A  noteworthy  group  was  composed  of  those  men  who  became  conscious 
of  their  defective  sight  because  for  the  first  time  in  their  lives  they  were 
forced  to  live  a  nocturnal  life  and  could  contrast  their  vision  with  that 
of  other  men  who  were  normally  sighted.  Almost  invariably  they 
were  ametropes.  They  have  been  aptly  described  by  M.  Landolt  as 
noclural  atnhlyopes.  Naturally  many  soldiers  were  found  who  did  not 
belong  to  the  "functional"  group,  but  were  night-blind  because  they 
were  the  subjects  of  chorioretinitis  and  pigmentary  degeneration  of 
the  retina  which  was  not  discovered  wiien  they  entered  the  service. 
Augstein  has  desciibed  a  fundus  apix'arance.  the  so-called,  whiti'-gray 
fundus,  which  he  atlrihuted  to  decoloration  of  the  pigment  epithelium.^ 

Krienes  divides  the  atTection  into  acute  est<enti(U  nyctalopia  (hemer- 
alopia)  and  chronic  nyctalopia,  and  he  gives  the  following  syllabus  of 
symptoms:  Decided  drcMd  of  light,  abnormal  width  of  the  pupil  in  the 
(lark,  depreciation  of  the  cenfial  (iiiant  it  alive  color-sense,  particularly 
the  blue  sense  in  daylight,  ii.aiiouiiig  of  the  color-lields  in  daylight, 

'  ('onsiilt  "Ninlit-liliiidiic.s.s  in  Wiufaiv"  hy  Hircli-Hirsohfcld,  Arch.  f.  Opiitlial., 
vol.  xcii,  pt.  II,  I'.tUi,  and  "N'octiinial  N'i.sual  Defects  ainuUK  .Sjldici-s,"  by  Marc 
Landolt,  Arch.  rl.  <  )i)lillial..  .July   Aiij:  .  I'.HT 


SNOW-BLINDNESS  559 

particularly  the  blue  field,  abnormal  shrinking  of  the  visual  field 
for  white  and  colors  in  increasing  twilight.  Other  not  absolutely 
constant  symptoms  are  loss  of  visual  acuteness  by  daylight,  shrink- 
ing of  visual  field  for  white  in  daylight,  retinal  tire  field,  paresis  of 
accommodation,  epithelial  xerosis,  erythropsia,  and  xanthopsia  (see 
also  page  247). 

Night-blindness  is  occasionally^  a  family  disorder.  Bordley  has 
described  a  negro  family  of  night-blind  persons  extending  over  five 
generations.  The  subjects  eventual^  became  blind,  and  shortly  after 
blindness  death  ensued.  Nettleship  has  published  a  history  of  sta- 
tionary night-blindness  in  nine  consecutive  generations. 

Treatment. — This  includes  the  administration  of  iron,  quinin, 
strychnin,  and  cod-liver  oil,  according  to  the  indications.  Dark- 
colored  glasses  should  be  worn.  If  scurvy  is  present,  the  diet  and 
remedies  suited  to  this  condition  should  be  prescribed.  Suitable  diet 
is  important  in  all  cases.     Refractive  error  should  be  corrected. 

Day=blindness  (Often  incorrectly  termed  Nyctalopia,  but  properly 
named  Hemeralopia) . — This  is  an  affection,  or  rather  a  symptom,  as  the 
name  implies,  characterized  by  the  fact  that  its  subjects  see  better  on 
dull  days  and  in  the  dark  than  in  a  bright  light.  The  visual  field  is  not 
concentrically  contracted. 

This  symptom  occurs  with  the  condition  described  by  Arlt  as  retini- 
tis nyctalopia,  and  with  orbital  optic  neuritis  of  the  chronic  type 
(tobacco  amblyopia,  see  page  539).  It  also  occurs  in  other  affections 
of  the  optic  nerve  and  in  some  diseases  of  the  retina.  The  same 
condition  may  be  present  in  certain  congenital  anomaHes — albinism, 
coloboma  of  the  iris,  and  irideremia.  It  also  occurs  as  an  idiopathic 
affection,  and  may  develop  in  those  who  have  long  been  excluded 
from  the  light.  It  may  be  congenital,  and  may  be  associated  with  an 
amblyopia  of  like  origin. 

A  tonic  treatment  should  be  tried  and  the  retina  gradually  educated 
to  sustain  bright  light. 

Snow=bIindness. — As  this  ordinarilj-  is  seen  in  northern  regions, 
it  is  an  affection  of  the  conjunctiva.  There  are  burning  pain,  photo- 
phobia, blepharospasm,  hyperemia  of  the  conjunctiva,  and  chemosis. 
In  severe  cases  there  may  be  ulceration  of  the  cornea.  The  pupils  are 
small,  and  there  is  congestion  of  the  retina.  The  visual  acuteness  may 
be  unaffected,  or  it  may  be  distinctly  lessened,  especially  if  corneal 
complications  arise;  under  these  conditions  restricted  visual  fields, 
both  day-  and  night-blindness,  red-green  blindness  (Lohmann),  and 
scotomas  have  been  observed.  The  local  irritation  in  snow-blindness 
is  analogous  to  sunburn,  and  like  it  has  been  attributed  to  the  action 
of  ultraviolet  rays.  (Widmark).  The  pain  caused  by  glare  is  due  to 
excessive  contraction  of  the  orbicularis  and  to  pressure  of  the  supra- 
orbital nerve  against  the  frontal  bone. 

Symptoms  analogous  to  so-called  "  snow-bhndness  "  develop  as  the 
result  of  exposure  of  unprotected  eyes  to  any  type  of  light  rich  in  ultra- 
violet rays — for  example,  a  naked  arc  light  {electric  ophthalmia) ;  molten 


560    AMBLYOPIA,    AMAUROSIS,    AND    DISTURBANCES    OF  VISION 

metal  in  electric  welding;  the  flash  of  a  short  circuit  high-tension  cur- 
rent, and  a  mercury  vapor  lamp.  To  the  injurious  effect  of  light  in 
these  circumstances,  interpreted  by  the  irritative  phenomena  already 
described,  Parsons  has  applied  the  term  photophthahnia.  Although 
the  ultraviolet  rays  probably  cause  the  greater  damage,  rays  of 
greater  wave  length-^infra-red  and  luminous  rays — are  also  capable 
of  harmful  action.  For  a  long  time  after  subsidence  of  photoph- 
thahnia there  may  be  persistent  asthenopia,  ciliary  pain,  frontal  and 
other  placed  headaches.  Those  who  are  much  engaged  in  work  with 
Rontgen  rays  often  suffer  from  decided  conjunctival  hyperemia  or 
positive  conjunctivitis  (x-ray  conjunctivitis). 

Experimentally,  it  has  been  demonstrated  that  ultraviolet  rays 
may  cause  changes  in  the  lens  (Hess)  and  in  the  retina  (Birch-Hirsch- 
feld).  These  changes  are  not  likely  to  occur  under  ordinary  conditions 
in  healthy  persons.  The  lens  protects  completely  the  retina  of  the 
normal  eye  (Verhoeff  and  Bell).  Special  forms  of  glass  supposed  to 
have  the  power  of  absorbing  ultraviolet  rays  have  been  devised;  all 
of  them  have  a  greenish-yellow  tint,  chief  among  them  are  "Enix- 
anthos,"  Fieuzal  glass,  and  "Euphos"  glass.  According  to  Parsons, 
almost  colorless  didymium  glass  is  the  best  protection  against  ultra- 
violet rays.  The  chief  usefulness  of  protective  glasses,  accorchng  to 
Verhoeff  and  Bell,  is  not  so  much  in  their  absorption  of  any  sjiecific 
radiations,  as  in  their  effect  in  reducing  the  total  amount  of  light  so 
that  it  ceases  to  be  dazzling.^ 

Erythropsia,  or  Red  Vision.^ — Colored  vision  in  glaucoma  (irid- 
escent vision),  in  the  form  of  variously  tinted  halos  about  the  lamp- 
lights, has  been  described,  and  patients  with  blind  eyes  occasionally 
complain  of  being  conscious  of  colored  lights,  owing  probably  to  some 
irritation  of  the  visual  centers. 

Erythropsia  in  most  instances  has  been  noted  after  cataract  extrac- 
tion. Visual  acuteness  is  not  affected,  but  everything  appears  of  a 
red  or  violet  color.  According  to  Fuchs,  erythropsia  can  be  caused  by 
the  visible  rays  alone.  Verhoeff  and  Bell  deny  that  ultraviolet  rays, 
as  has  been  stated,  are  concerned  with  the  production  of  erythropsia, 
which  they  believe  is  merely  "a  special  case  of  color  fatigue."  An 
uncommon  phenomenon  is  blue  vision  or  kyanopsia.  Bromid  of 
potassium  is  indicated,  and  is  said  to  ameliorate  these  symptoms. 
Green  vision  has  been  noted  after  cataract  extraction  and  corneal 
wounds,  and  in  connection  with  diseases  of  the  optic  nerve  and  retina — 
for  example,  wilh  tabetic  ()j)tic-nerve  atrophy  (H.  W.  Dodd). 

Micropsia  antl  niacropsia  have  been  di'sciibed  in  connection  with 
syphilitic  retinitis.  Thej'  may  appear  as  functittnal  (hsorders  in 
hysteric  ca.ses. 

'  "Some  KfTpcts  of  Hrinht  Linht  on  tln'  Kyos,"  by  .1.  HciIk  it  I'arsoiis.  Trans, 
of  Section  of  ()j)litli!ilin(ilo^'y,  Anier.  Mcil.  Assoc,  lUlO.  l'\)r  !i  full  fonsidenition 
of  this  subject  consult  "The  rntholoniciil  EITeets  of  liiuliiint  EnerRy  on  the  Eye  " 
by  F.  II.  Verhoeff  and  Louis  Hell.  ProceedinKs  of  the  .-Vinericnn  Academy  of 
Arts  ant!  Sciences,  vol.  51,  No.  13,  July,  lUlU. 


CHAPTER  XVIII 

AMBLYOPIA   OF  THE  VISUAL  FIELD,   SCOTOMAS  AND 
HEMIANOPSIA 

The  importance  of  perimetric  measurements  in  the  study  of  various 
forms  of  ocular  disease,  especially  in  glaucoma  and  in  affections  of  the 
retina,  choroid,  and  optic  nerve,  has  been  noted  (for  the  methods  of 
examination  consult  Chapter  II).  There  remain  to  be  considered  cer- 
tain conditions  in  which  a  defect  in  the  field  of  vision  constitutes  one 
of  the  most  prominent  symptoms. 

1.  Partial  Fugacious  Amaurosis  (Flimnier-scotom;  Migraine 
Ophtholmique). — The  symptoms  are:  A  sense  of  vertigo;  a  positive 
darkening  of  the  field  of  vision  of  each  eye,  beginning  at  the  center 
and  widening  out  in  a  vibratory  movement  until  it  overspreads  the 
field,  with  corresponding  sinking  of  the  central  acuteness  of  sight; 
or  a  scotoma  surrounded  bj-  flashing  zigzag  lines,  and  cessation  of  the 
amaurosis  with  the  onset  of  headache  and  vomiting;  a  transitory 
hemianopsia  without  light  or  flashing  is  also  described.  These 
symptoms  may  be,  and  often  are,  a  prodrome  of  hemicrania  or  migraine, 
but  they  also  arise  without  it,  and  may  occur  in  syphilitic  subjects. 
The  condition  probablj'  depends  upon  circulatory  disturbances  in 
the  occipital  lobes,  or  upon  vascular  spasm.  Occasionally  the  hem- 
ianopsia of  migraine  after  long  periods  of  time  and  repeated  attacks, 
becomes  permanent. 

The  treatment  is  diiected  toward  the  headache,  the  partial  amauro- 
sis being  exceedingly  temporar}^  in  character,  and  includes  the  meas- 
ures suited  to  migraine.     Syphilis  calls  for  the  usual  remedies. 

2.  Amblyopia  of  the  Visual  Field  (Anasthesia  Retinoe). — This 
functional  disturbance  as  part  of  a  general  neurosis  has  been  described 
on  page  462.  Because  of  the  peculiar  changes  in  the  visual  field  many 
authors  prefer  the  name  "amblyopia  of  the  visual  field"  to  that  of 
"anesthesia  of  the  retina." 

Fatigue  restrictions  of  the  visual  field,  in  the  form  already  described 
are  seen  after  injuries  (traumatic  neurosis),  and  sometimes  with  trau- 
matic  anesthesia  of  the  retina.  The  element  of  hysteria  cannot  always 
be  eliminated,  and  the  phenomena  described  in  connection  with 
hysteric  ocular  manifestations  may  predominate. 

3.  Scotomas. — Any  lesion  which  blots  out  the  function  of  a  por- 
tion of  the  retina  produces  a  corresponding  blind  area  in  the  field  of 
vision,  or  a  scotoma — for  example,  a  hemorrhage,  a  patch  of  retino- 
choroiditis  in  the  macular  region,  or  spots  of  disseminated  choroiditis 
in  the  periphery  of  the  eye-ground.  In  rare  instances  the  scotoma  seen 
by  a  patient  with  central  retinochoroiditis  is  colored.  Papillitis  causes- 
an  enlargement  of  the  natural  blind-spot,  and  retrobulbar  neuritis  a- 

36  561 


562 


AMBLYOPIA  OF  VISUAL  FIELD,  SCOTOMAS,  AND  HEMIANOPSIA 


central  scotoma.  The  different  forms  which  scotomas  assume  are 
described  on  page  88.  The  scotomas  associated  with  chronic  glau- 
coma are  depicted  on  page  404.  Unilateral  scotomas  may  occur  in 
hysteria,  in  neurasthenia  (central  exhaustion  scotomas),  with  men- 
strual disorders,  in  obstruction  of  the  central  artery  of  the  retina,  and 
with  disease  of  the  macular  cortical  center.  Ring-shaped  or  annular 
scotomas  have  attracted  much  attention.  Ordinarily,  they  are  to  be 
explained  by  the  presence  of  chorioretinitis,  but  the  statement,  often 
made,  that  they  always  are  of  retinal  origin  is  not  correct.  They 
interpret  certain  lesions  of  the  optic  nerve,  and  in  addition  to  those 
caused  by  chorioretinitis  and  pigmentary  degeneration  of  the  retina 
(page  485),  are  those  which  occur  with  optic  neuritis,  choked  disk, 
sinusitis  (ethmoid  and  sphenoid  disease),  and  chronic  glaucoma  (see 

page  404).  Thej'  have  also  been  ob- 
served in  hysteric  subjects  and  have 
been  reported  as  part  of  the  symp- 
tomatology of  migraine  (Zentmayer). 
In  addition  to  these  diseases  cer- 
tain affections  of  the  optic  nerve  are 
accompanied  by  a  scotoma.  Follow- 
ing in  part  the  classification  of  Jensen, 
these  may  be  described  as:^ 

(a)  Central  Amblyopia  with  Sco- 
toma {Toxic  Anihlyopia) . — This  affec- 
tion has  been  described  on  page  538. 

(6)  Chiasmal  Central  Amblyopia. 
Central  scotomas,  difficult  to  dis- 
tinguish from  those  occurring  in  toxic 
amblyopia,  are  sometimes  the  initial  signs  of  chiasm  disease.  Accord- 
ing to  Nettleship,  the  loss  of  the  central  field  in  the  earlier  stages  is 
more  abruptly  defined  than  in  tobacco  aml)lyopia.  With  increase  in 
the  size  of  the  growth  they  may  expand  into  complete  bitemporal 
hemianopsia  (see  page  563).  As  the  visual  phenomena  in  pituitary 
body  disease  have  assumed  such  importance  in  ophthalmic  and  neuro- 
logic examinations,  a  brief  r(''Suni('M)f  thcni  follows: 

Visual  Phenomena  in  Pituitary  Body  Disease. — These  consist  in 
impairment  of  vision,  varying  from  blurred  sight  to  complete  blindness; 
intra-ocular  optic-nerve  alterations,  varying  from  partial  or  general 
pallor  of  the  nerve-head  to  partial  or  complete  atrophy,  less  frequently 
postneuritic  atrophy,  choked  disk,  and  non-prominent  optic  neuritis; 
alterations  in  tlu^  visual  fields  for  form  and  colors,  (v^pei'ially  homony- 
mous and  heteronymous  hemianopsia  and  scotomas.  Other  ocular 
symptoms  which  have  been  described  are  visual  hallucinations,  chro- 
matoi)sia,  especially  cvanopsia,  persistent  piu)tophol)ia.  palsy  of  various 
exterior   ocular   muscles,    nystagnuis,   e\()i)lit  li.-ihiios,    thickening   and 

'  A  tnui.sliitioii  by  Ci.  A.  licrry  of  ii  lengthy  iihstract  of  .li'iisiMra  iirtiolo  on 
"Disc'jises  of  the  Eye  Accoinpiinied  b}'  a  Central  Scotoma"  appeared  in  the  Dpli- 
thalniic  Review,  January,  IK'Jl. 


Fig. 


240.  —  Ring-shai)ed     scotoma 
in  a  case  of  neuritis. 


SCOTOMAS  563 

pigmentation  of  the  eyelids  with  hypertrophy  of  the  palpebral  glands. 
A  very  early  symptom,  noticeable  sometimes  for  weeks  and  months 
before  fundus  changes  are  detected,  is  a  form  of  blurred  vision,  charac- 
terized by  ill-defined  indistinctness  of  sight.  Visual  disturbances  are 
more  frequent  in  primary  hypopituitarism  than  in  acromegaly.  Gen- 
erally the  ophthalmoscopic  appearances  are  those  of  so-called  simple 
atrophy;  often  the  disk  has  a  somewhat  waxy  appearance;  atrophic 
cupping  is  not  evident;  choked  disk  is  rare.  Even  where  the  pallor  of 
the  disk  gives  every  indication  of  simple  atrophj^,  marked  improvement 
in  vision  may  follow  successful  operation  or  prolonged  organotherapy. 
Evidently  there  is  a  physiologic  block  to  light  impulses,  and  not 
at  this  period  a  destruction  of  the  nerve-fibers.  While  bitemporal 
hemianopsia  is  a  common  visual  field  defect,  homonymous  lateral 
hemianopsia  is  not  infrequent,  especially  if  with  homonymous  defects 
are  included  what  Gushing  calls  the  tendencies  in  this  direction.  In 
all  cases  the  defect  for  colors  precedes  that  for  form,  but,  if  the  visual 
fields  are  measured  with  small  test-objects  (page  85)  the  early  changes 
can  be  detected  without  recourse  to  color  tests,  which  often  are 
unsatisfactory.  There  may  be  unilateral  hemianopsia  or  one  eye 
blind  and  the  temporal  field  of  the  other  eye  defective.  In  bitemporal 
hemianopsia  in  this  disease  it  will  be  found  that  the  temporal  field 
tends  to  be  lost  from  above  downward.  This  is  the  so-called  "tem- 
poral slant."  A  peculiarity  of  the  visual  fields  in  pituitary  body 
disease  is  the  variations  which  they  undergo,  hence  the  necessity  of 
frequent  perimetric  observations. 

Central  and  paracentral  scotomas  are  common,  especially  the  para- 
central varieties;  they  may  be  situated  to  the  outer  side  of  each  fixa- 
tion-point, that  is,  they  are  bitemporal  hemianopic  scotomas.  These 
scotomas  may  antedate  the  more  elaborate  visual  field  defects  and  they 
may  expand  into  complete  hemianopsia.  Sometimes  the  defect  may 
be  detected  upward  and  outward,  forming  a  quadrant.  For  a  correct 
interpretation  of  pituitary  body  disease  the  visual  fields  must  be 
frequently  examined  with  test-objects  of  various  sizes  (page  85)  as 
Gushing  and  Walker  have  insisted  in  their  admirable  studies  of  the 
subject.  The  search  for  scotomas  is  important  as  is  their  interesting 
relation  to  later  visual  field  defects,  as  shown  by  the  observations  of 
Uhthoff,  HoUoway  and  the  author  and  other  writers.  They  have 
demonstrated  the  necessity  of  frequent  examination  of  the  visual 
fields  with  test-objects  of  various  sizes. 

(c)  Stationary  Optic  Atrophy  with  Scotoma.— This  is  characterized 
by  a  scotoma  similar  to  the  one  which  occurs  in  toxic  amblyopia,  but 
much  more  decided.  There  are  marked  diminution  of  central  vision, 
a  depreciation  of  the  color-sense,  and  ophthalmoscopically  the  appear- 
ances of  optic-nerve  atrophy.  The  process  is  stationary,  and  vision 
does  not  improve  under  treatment.  Jensen  finds  this  affection  exclu- 
sively in  men  before  their  thirty-fourth  year.  It  has  a  hereditary 
tendency,  and  is  said  to  be  caused  by  exhaustion  and  lack  of  sleep. 
Sometimes  no  cause  can  be  demonstrated.     Preceding  the  atrophy 


564     AMBLYOPIA  OF  VISUAL  FIELD,  SCOTOMAS,  AND  HEMIANOPSIA 

there  may  be  slight  neuritis.     Hereditary  optic  neuritis,  with  central 
scotoma    (Lohor's   disoaso)  ha?  l)oon  dopcrihod  fpago  536). 

(d)  Progressive  Optic  Atrophy  with  Scotoma.^Thi.-^  includes  the 
class  of  cases  in  wliicii  tiie  f)pti('-nerve  atrophy  of  spinal  disease  (tabes 
dorsalis  and  disseminated  sclerosis)  is  associated  with  a  scotoma.  The 
scotoma  is  central  and  shaped  like  the  one  in  tobacco  amblyopia,  but 
as  the  disease  progresses  the  peripheral  field  contracts,  and  finally  it 
becomes  difhcult  to  detect  the  central  defect.  A  central  scotoma  in 
tal)etic  atrophy  of  the  optic  nerve,  according  to  Fuchs,  is  of  more  fre- 
quent occurrence  than  the  ordinary  records  would  seem  to  indicate. 
The  scotoma  is  nearly  always  bilateral,  and  he  regards  it  not  as  an  acci- 
dental complication,  but  as  an  integral  part  of  the  tabetic  process. 
Some  authors  maintain  that  the  infiu(>nce  of  tobacco  and  alcohol  in  the 
formation  of  these  scotomas  cannot  be  eliminated.  Central  scotoma 
is  common  in  insular  sclerosis. 

(e)  Optic  Neuritis  with  Scotoma. — .\n  unusual  symptom  of  ihtra- 
ocular  neuritis  caused  by  meningitis  is  a  central  scotoma,  either  relative 
or  absolute.  The  student  should  not  confuse  this  with  an' enlargement 
of  the  natural  blind-spot  due  to  the  inflanunatory  swelling  of  the  nerve- 
head.  Ring  scotoma  has  been  reported  with  choked  disk  cau.sed  by 
brain  tumor,  and  in  optic  neuritis  due  to  sinusitis  a  central  scotoma 
may  develop  (see  also  page  647). 

As  has  already  been  pointed  out,  the  cause  of  central  scotoma  in 
orbital  optic  neuritis  (toxic  amblyopia)  is  degeneration  of  the  papillo- 
macular  bundle  in  the  optic  nerve  or  a  destruction  of  the  macular 
ganglion-cells. 

Obscuration  of  One=half  of  the  Visual  Field,  or  Hemian= 
Opsia.' — In  diseases  of  the  e\'e — c.  g.,  glaucoma — one-liah'  of  the  \-isuai 
field  may  be  wanting,  and  also  in  optic-nerve  atrophy  and  neuritis, 
even  if  they  are  unconnected  with  disease  of  the  visual  pathway. 
These  cases,  however,  are  not  included  in  the  present  account. 

Hemianopsia  is  that  defect  of  vision  cliaiacterized  by  an  ol>scura- 
tion,  or  loss  of  one-half  of  the  field,  which  occuis  under  the  influence  of 
a  lesion  situated  at  the  optic  chiasm,  in  the  optic  tract,  in  th<'  visual 
radiations,  or  at  their  ultimate  destination  in  tlie  brain  (occipital  lobe). 

Visual  Tract. — Tho  visual  trart,  or  visual  coiuluctiou  patlis,  may  hricfly  lu* 
(Icscrihcd  as  follows: 

The  retina  is  a  lii(j;lily  evolved  .structure,  whieli,  from  the  histolo^ie  staiulpoiut. 
may  l)e  dividiMJ  into  three  layers:  (1)  The  layer  of  the  neuro-epHheliitm,  composed  of 
two  strata,  namely,  the  layer  of  rods  and  cotiex  and  tiu>  external  nnelear  hiyer,  the 
foniH'r  eonstitutinn  the  s|)ecialized  outer  portions  and  the  latter  tiie  luieh'.'ited 
bodies  of  the  ri.snal  cells;  (2)  the  layer  of  the  bipolar  cells,  which  l>y  some  authorities 
are  looked  ujion  as  the  peripheral  visual  neurons;  ('A^  the  layer  of  the  (/(inylion-cells. 

The  lonj;  processes,  or  axons,  of  the  nannlion-cells  pa.ss  into  the  nerre-JilM-r  layer 
of  the  retina,  reaching  the  luijiilla  or  nerve-head,  and  proceed  to  th(>  optic  nerve^ 
Iluvitifr  rea(;hed  the   optic  chiasm,  n  portion  of  tho  fihera  of  one  optic  nerve  cross 

'  Tho  terms  hemio/na  and  hemianopsia  aro  often  usoil  synonymously.  Really, 
hemiopia  sinnilies  loss  iit  the  percei)tivo  power  of  one-half  of  the  retin.a,  while 
hemianopsia  means  ohscuralion  or  lo.ss  of  one-half  of  tlu'  visual  field  (Sequin). 
Other  iiMMies  which  are  used  arc  hemiaiiopia  ami  hcmiaMepsi.a. 


OBSCURATION  OF  ONE-HALF  OF  VISUAL  FIELD,  OR  HEMIANOPSIA  565 

over  and  enter  the  optic  tract  of  the  opposite  side,  forming  the  crossed  fascicuhis  > 
while  a  certain  number  of  other  fibers  do  not  cross,  but  enter  the  optic  tract  of  the 
same  side,  forming  the  non-crossed  fasciculus.  The  non-crossed  fasciculus  arises 
chiefly  from  the  temporal  side  of  the  retina,  while  the  crossed  fasciculus  arises 
from  the  ganglion-cells  of  the  nasal  side  of  the  retina.  The  bundle  from  the  macula 
lutea,  called  the  macular  fascicuhis,  or  papillo macular  bundle,  in  general  terms,  is 
situated  in  the  central  part  of  the  optic  nerve  and  maintains  its  central  position 
in  the  optic  chiasm  and  in  the  optic  tract,  and  is  composed  of  crossing  and  direct 
fibers.  Thf  optic  tract  on  each  side  behind  the  chiasm  passes  around  the  cerebral 
peduncle  of  the  same  side  and  arrives  at  the  junction  of  the  interbrain  and  mid- 
brain, and  divides  into  a  lateral  and  a  medial  root.     The  fibers  of  the  lateral  root 


los      Ion. 

Fig.  241. — Diagram  illustrating  the  visual  path  and  its  relation  to  the  visual  field, 
left  lateral  hemianopsia  being  shown  (Seguin).  L.  T.  F.,  left  temporal  half-field; 
R.  X.  F.,  right  nasal  half-field;  O.  S.,  left  eye;  O.  D.,  right  eye;  N.,  nasal,  and  T., 
temporal  halves  of  the  retinas;  X.  0.  S.,  left  optic  nerve;  A'.  O.  D.,  right  optic  nerve; 
F.  C.  S.,  left  crossed  fasciculus;  F.  L.  D.,  right  lateral  or  non-crossed  fasciculus;  C, 
Chiasm  or  decussation  of  the  fasciculi;  T.  O.  D.,  right  optic  tract;  T.  O.  S.,  left  optic 
tract;  C  G.  L.,  corpus  geniculatum  laterale  (medial  corpus  geniculatum  and  its  arms  are 
omitted);  L.  O.,  optic  lobes  (corpora  quadrigemina) ;  P.  O.  C,  primary  optic  centers 
(including  corpora  quadrigemina,  corpora  geniculata,  and  pulvinar  of  the  optic  thala- 
mus);  F.  0.,  optic  fasciculus,  radiating  visual  fibers  of  Gratiolet  in  the  internal  capsule 
C.  P.,  posterior  horn  of  the  lateral  ventricle;  G.  A.  region  of  the  gyrus  angularis;  L.  0.  S., 
left  occipital  lobe;  L.  O.  D.,  right  occipital  lobe;  Cu..  cuneus  and  subjacent  gyri  con- 
stituting the  cortical  visual  center  in  man.  The  shaded  lines  represent  the  parts  con- 
nected with  the  right  halves  of  the  retinas. 

terminate  in  the  lateral  geniculate  body,  in  the  pulvinar  of  the  thalamus,  and  in  the 
superior  colliculus  of  the  corpora  quadrigemina.  These  structures  have  been  desig- 
nated the   primary  visual  gav.glia  or  primary  optic  centers.^     The  corpora  quadri- 

^  According  to  W.  G.  Spiller,  the  chief  "primary"  optic  center  is  the  external 
geniculate  body.  The  pulvinar  of  the  optic  thalamus  is  also  an  important  "pri- 
mary" optic  center.  The  anterior  colliculus  of  the  quadrigeminal  body  in  man 
has  an  unimportant  relation  to  vision.  The  hypothalmic  body,  the  habenula,  the 
internal  geniculate  body,  probably  are  not  part  of  the  visual  sj'stem  (consult 
Spiller,  "A  Case  of  Complete  Absence  of  the  Visual  Sj'stem  in  an  Adult,"  Univ.  of 
Penna.  Medical  Bulletin,  February,  1902). 


566    AMBLYOPIA  OF  VISUAL  FIELD,   SCOTOMAS,   AND   HEMIANOPSIA 


gemina  are  not  concerned  in  the  act  of  vision,  but  in  the  activity  of  the  pupil. 
The  medial  root  of  the  optic  tract  has  no  connection  either  with  the  retina  or  with 
the  optic  centers  of  the  interbrain  and  midbrain. 

From  the  regions  just  described  fibers  proceed  backward  through  the  posterior 
part  of  the  internal  capsule  to  the  cortex.  These  are  the  optic  or  visual  radiations, 
or  fibers  of  Gratiolet  or  of  Wernicke.  Passing  through  the  internal  capsule,  they 
cross  the  sensitive  fibers  coming  down  from  the  hemisphere,  and  spreading  out 
like  a  fan,  rise  upward,  wind  outside  of  the  tip  of  the  lateral  ventricle,  to  reach  their 
destination  at  the  lower  part  of  the  median  surface  of  the  occipital  lobe — that  is, 
the  cortical  termination  of  the  visual  tracts.  The  exact  area  occupied  by  the  corti- 
cal center  of  vision  has  not  been  determined.  In  general  terms  it  is  situated  about 
the  cuneus  and  calcarine  fissure,  and  does  not  comprise  the  whole  of  the  occipital 
lobe. 

By  comparing  the  description  of  the  varieties  of  hemianopsia 
which  follow  with  Fig.  241,  the  student  will  understand  the  mechanism 
of  their  development. 

Varieties  of  Hemianopsia.^ — Hemianopsia  is  divided  into  horizontal, 
in  which  the  dividing-line  between  the  darkened  and  preserved  field  is 
horizontal;  and  vertical,  in  which  the  dividing-line  is  vertical. 


270 

L.  R. 

Fio.  242. — Bitemporal  hemianopsia.  The  shaded  areas  represent  the  portions  of 
the  fields  which  are  dark,  and  it  is  svident  that  there  are  entire  loss  of  both  tempor.al 
fields  and  some  contraction  of  the  preserved  fields  (from  a  case  of  acromegaly). 

1.  Horizontal  hemianopsia  (altitudinal)  may  be  inferior  or  superior, 
both  lower  or  both  upper  half-fields  being  wanting.  In  addition  to  dis- 
eases of  the  eye,  it  is  possible  that  such  a  condition  could  arise  under 
the  influence  of  a  lesion  so  situated  as  to  press  upon  the  upper  or  lower 
part  of  the  chia.sm,  or  downward  upon  one  optic  tract,  or  upon  the  lower 
or  upper  part  of  both  optic  nerves.  A  double  lesion  in  front  of  the 
chiasm  may  produce  loss  of  the  upper  half  of  llie  field  in  one  eye  and  of 
the  lower  half  of  tiie  field  in  the  other  eye. 

2.  Vertical  Hemianopsia. — This  is  subdivided  into  several  varieties : 
(a)  Bitemporal  hejnianopsia  (peripheral),  in  which  both  temporal 

field.s  an;  wanting,  is  eliaracteristic  of  lesion  of  the  chiasm.  The  ilefect 
is  not  necessarily  comj)lete  from  the  beginning.  Color-scMise  at  first 
may  be  alone  affected,  followetl  later  by  loss  of  form-  and  light-sense. 
In  place  of  complete  bitemporal  hemianopsia  there  may  be  paracentral 
or  bitemporal  hemiopic  scotomas,  which  gradually  broaden  into  l)it(>m- 
poral  hemianopsia  (sec  also  pages  5G2  and  503).     There  arc  a  number 


OBSCURATION  OF  ONE-HALF  OF  VISUAL  FIELD,  OR  HEMIANOPSIA  567 

of  types  or  combinations  of  bitemporal  visual  field  defects.  Wildbrand 
described  nine,  Gushing  and  Walker  have  elaborated  his  list. 

(6)  Binasal  hemianopsia,  in  which  both  nasal  fields  are  wanting,  is 
rare.     Unilateral  nasal  hemianopsia  also  occurs. 

(c)  Homonymous  hemianopsia  (central),  in  which  the  correspond- 
ing half  of  the  field  in  each  eye  is  wanting:  thus,  both  right  or  both 
left  fields  are  darkened,  in  the  former  case  indicating  loss  of  function 


Fig.  243. — Left  homonymous  hemianopsia,  from  a  case  of  gunshot  wound,  with  sus- 
pected lesion  of  the  right  cuneus.  The  shading  shows  where  vision  was  lost  (from  a 
patient  under  the  care  of  the  late  Dr.  S.  Weir  Mitchell  in  the  Infirmary  for  Nervous 
Diseases). 

of  the  left  half  of  each  retina  and  designated  right  homonymous  lateral 
hemianopsia,  and  in  the  latter  case  indicating  loss  of  function  of  the 
right  half  of  each  retina,  and  designated  left  homonymous  lateral 
hemianopsia  (see  Figs.  243  and  244). 

This  is  the  commonest  form  of  hemianopsia. 

Hemianopsia  may  be  complete — i.  e.,  the  entire  half  of  each  field  is 
wanting — or  incomplete,  i.  e.,  a  portion  of  each  half -field  is  wanting,  the 


Fig.  244. — Right  homonymous  hemianopsia  (from  a  patient  under  the  care  of  the  late 

Dr.  Wharton  Sinkler). 

defect  usually  being  in  the  form  of  a  quadrant  (Figs.  243-245).  The 
preserved  half-fields  may  be  of  their  normal  size,  or  they  may  exhibit 
concentric  contraction. 

Finally,  the  hemianopsia  may  be  absolute — i.  e.,  all  the  three  func- 
tions of  sight  (perception  of  light,  of  form,  and  of  color)  are  wanting — 


568   AMBLYOPIA  OF  VISUAL  FIELD,   SCOTOMAS,   AND   HEMIANOPSIA 

or  it  may  be  relative,  i.  e.,  perception  of  color  only  is  lacking,  light-sense 
and  form-sonso  being  preserved;  or  perception  of  color  and  form  is 
wanting  in  tiie  deficient  area  of  the  field,  l)ut  the  light-sense  is  preserved. 
Those  cases  in  which  the  half-defect  is  present  for  colors  alone  are  de- 
scribed under  the  name  Iwmony/fious  he miachromatopsia .  They  have 
been  attributed  to  a  cortical  lesion  of  less  intensity  than  one  which  pro- 
duces absolute  hemianopsia.  In  a  remarkable  case  of  this  kind  which 
the  author  hasstudied  with  Dr.  J.  William  White,  at  the  onset  the  hemi- 
anopsia was  absolute;  later  light-sense  and  form-sense  returned.  The 
obliteration  of  the  color-.sense  remained,  although  in  all  other  respects 
the  patient  recovered.  Gordon  Holmes,  however,  doubts  if  it  has 
been  conclusively  shown  that  color  perception  may  be  lost  in  an^' 
part  of  the  field  when  that  of  light  or  white  is  undisturbed;  in  short 
his  observations  tend  to  show  that  an  isolated  loss  or  dissociation  of 
color  vision  is  not  produced  by  cerebral  lesions. 


Fig.  245. — Quadrant  homonymous  anopsia  or  tetranopsia.  shading  as  before.     .\  t|uad- 
rant  of  each  field  is  wanting.     The  lesion  is  probably  in  the  cuneiis. 

The  dividing-line  in  hemianopsia  may  exactly  cut  the  fixing-point, 
or,  as  is  usual,  it  may  pass  around  this  point  and  leave  it  within  the 
region  of  preserved  vision.  The  want  of  uniformity  between  th(>  seeing 
and  the  blind  areas  may  be  manifested  by  the  failure^  of  the  dividing- 
line  to  coincide  with  the  vertical  meridian  for  some  distance,  by  its 
assuming  an  oblique  or  irregular  direction,  or  by  forming  an  open  angle. 
The  border  line  between  the  blind  and  seeing  halves  of  the  field  is 
more  irregular  in  lesions  of  the  chiasm  than  in  those  posterior  to  this 
position. 

A  number  of  cases  of  dmihlc  homonymous  hemianopsia  have  been 
recorded,  due  to  a  cerebral  lesion  on  each  side  of  the  l)rain.  In  these 
circumstances  theic  is  usually  preserved  a  siiiall  central  lield  of  each 
e3'e,  that  is  the  macula  is  exempted.  Small  homonymous  paracentral 
scotomas,  the  so-called  iiKiriihir  licmidUDpsid  have  been  i-e|)oited  (,  Wild- 
brand).  Central  N'ision  m;i_\-  be  goo(l,  luit  ceitaiii  \isii;d  acts,  for 
instance  I'cadiiig,  are  much  ilislurbed. 

Significance  of  Hemianopsia.  T.\  pical  bitemporal  hemianopsia  of 
.I)ermanent  character  is  caused  by  a  lesion  tumor,  pituitar>'  body  dis- 
ease, aneurysm,  exostosis,  arterial  disease,  basal  syphilis,  tuberculosis, 


OBSCURATION  OF  ONE-HALF  OF  VISUAL  FIELD,  OR  HEMIANOPSIA  569 

etc. — which  destroys  the  conductivity  of  both  crossed  fascicuh,  leaving 
the  non-crossed  fascicuh  unaffected  (see  page  565).  It  is  a  common 
symptom  of  pituitar}-  body  disease  (neoplasm  or  struma).  Affec- 
tions of  this  region,  however,  maj'  cause  other  varieties  of  visual  field 
defects,  especially  paracentral  scotomas  as  noted  on  page  563,  and  the 
hemianopsia  caused  by  pituitary  body  lesions  is  not  always  bitemporal. 

A  true  chiasmal  variety  of  binasal  hemianopsia  probably  does  not 
occur,  although  the  visual  field  defect  has  been  attributed  to  disease  of 
the  lateral  angles  of  the  chiasm.  ]Most  of  the  cases  seem  best  explained 
by  a  bilateral  inflammation  of  the  trunks  of  the  optic  nerves  in  front  of 
the  chiasm.  Unilateral  hemianopsia,  if  not  caused  by  disease  within 
the  eye,  could  originate  from  injury  or  lesion  in  one  optic  nerve.  A 
nasal  hemianopsia  on  one  side  could  be  produced  by  a  lesion  affecting 
the  lateral  portion  of  the  chiasm  involving  the  non-crossing  fibers  of 
one  eye. 

Homonymous  lateral  hemianopsia  is  caused  by  a  lesion  situated  in 
the  occipital  lobe,  the  optic  radiations,  the  internal  capsule,  the  pri- 
mary optic  centers,  or  the  optic  tract  (see  Fig.  241). 

(a)  The  lesion  in  hemianopsia  is  on  the  opposite  side  of  the  dark  fields. 

(b)  If  the  preserved  fields  are  accompanied  by  concentric  contraction,  the 
smaller  half-field  will  be  in  the  eye  opposite  to  the  lesion;  contraction  of  the  pre- 
served half-field  is  most  common  with  lesions  of  the  cortex ,  but  also  may  occur  in 
lesions  of  the  tractus. 

(c)  If  the  hemianopsia  is  relative,  the  lesion  is  probably  in  the  cortex;  but  corti- 
cal lesions  are  not  excluded  by  absolute  hemianopsia. 

(d)  A  lesion  confined  to  the  cuneus,  or  to  it  and  the  gray  matter  immediately 
surrounding  it.  on  the  mesial  surface  of  the  occipital  lobe,  produces  homonymous 
lateral  hemianopsia  without  motor  or  sensory  symptoms,  at  least  without  these  as  a 
direct  consequence  of  the  lesion,  although  they  may  appear  as  indirect,  or,  as  they 
are  sometimes  called,  distant  symptoms. 

(e)  A  lesion  producing  typical  hemiplegia,  aphasia,  if  the  right  side  is  paralyzed, 
little  or  no  anesthesia  and  lateral  hemianopsia,  is  probably  due  to  disease  in  the 
area  supplied  by  the  middle  cerebral  artery. 

(/)  A  lesion  causing  hemiplegia,  hemianesthesia,  and  lateral  hemianopsia  is 
probably  situated  in  the  posterior  portion  of  the  internal  capsule. 

(g)  A  lesion  causing  hemianesthesia,  ataxic  movements  of  one-half  of  the  body, 
no  distinct  hemiplegia,  and  lateral  hemianopsia  could  be  situated  in  the  posterior 
lateral  part  of  the  optic  thalamus. 

(h)  A  lesion  causing  the  symptoms  of  disease  of  the  base  of  the  brain,  associated 
at  the  same  time  with  changes  in  the  pupil,  changes  in  the  nerve-head,  and  lateral 
hemianopsia,  could  be  situated  in  one  optic  tract  or  in  the  primary  optic  centers  on 
one  side. 

(?)  Incomplete  hemianopsia,  assuming  usuallj-  a  quadrant-shaped  defect,  may 
be  present  on  account  of  a  lesion  confined  to  the  lower  half  of  the  cuneus.  It  may 
also  occur  with  less  definite  limitations  in  lesions  of  the  subcortical  substance  of  the 
occipital  lobe  and  then  maj-  be  associated  with  other  symptoms,  as  hemiplegia  and 
hemianesthesia.  It  maybe  due  to  a  lesion  of  the  tract,  but  then  will  be  accom- 
panied by  other  symptoms  indicating  basal  disease,  or  to  a  lesion  of  the  external 
geniculate  body.  Quadrantic  hemianopsias  may  result  from  lesions  of  the  optic 
radiations  (Gordon  Holmes).     . 

(j)  A  hemianopsia  in  which  there  is  preservation  of  the  light-sense,  but  loss  of 
either  the  color-sense  or  the  form-sense  has  been  attributed  to  a  lesion  in  the 
cortex  of  the  visual  center. 


570    AMBLYOPIA  OF  VISUAL  FIELD,   SCOTOMAS,   AND   HEMIANOPSIA 

'  During  the  recent  war  the  opportunities  of  studying  the  effect  of  injuries 
of  the  brain  on  the  visual  field  were  extensive  and  a  large  literature  on 
this  subject  is  available,  which  could  not  be  analyzed  in  a  book  of  the  present 
scope.  The  conclusions  reached  bj-  Gordon  Holmes  and  W.  T.  Lister  on  the 
localization  and  organization  of  the  cortical  centers  of  vision  and  the  visual  dis- 
turbances which  may  be  produced  by  lesions  in  different  portions  of  the  brain, 
differ  in  some  respects  from  those  which  have  been  previously  held,  for  example, 
those  of  Henschen.     They  are  as  follows: 

"1.  The  upper  half  of  each  retina  is  represented  in  the  dorsal,  and  the  lower  in 
the  ventral,  part  of  each  visual  area. 

"2.  The  center  for  macular  or  central  vision  lies  in  the  most  posterior  part  of 
the  visual  cortex,  probably  on  the  margins  and  on  the  lateral  surfaces  of  the  occi- 
pital poles.     The  macula  has  not  a  bilateral  representation. 

"3.  The  center  for  vision  subserved  l)y  the  periphery  of  the  retina;  is  situated  in 
the  anterior  portions  of  the  visual  areas,  and  the  serial  concentric  zones  of  the  re- 
tina; from  the  macula  to  the  periphery  are  probably  represented  in  this  order 
from  behind  forwards  in  the  visual  cortex. 

"4.  Those  portions  of  the  retime  adjoining  their  vertical  axes  are  probably 
represented  in  the  dorsal  and  ventral  margins  of  the  visual  areas,  while  the  retina 
in  the  neighborhood  of  its  horizontal  axis  is  projected  on  to  the  walls  and  the 
floor  of  the  calcarine  fissures. 

"5.  Severe  lesions  of  the  visual  cortex  produce  complete  blindness  in  the  corre- 
sponding portions  of  the  visual  fields,  or  if  incomplete  an  amblyopia,  color  vision 
being  generally  lost  and  white  objects  appearing  indistinct,  or  only  more  potent 
stimuli,  as  abruptly  moving  objects,  may  excite  sensations. 

"6.  The  defects  of  vision  in  the  fields  of  the  two  eyes  are  always  congruous  and 
superimposable,  provided  that  no  abnormality  of  the  peripheral  visual  apparatus 
exists. 

"7.  Lesions  of  the  lateral  surface  of  the  hemispheres,  particularly  of  the  pos- 
terior parietal  regions,  maj^  cause  certain  disturbances  of  the  higher  visual  per- 
ceptual functions  with  intact  visual  sensibility,  as  loss  of  visual  orientation  and 
localization  in  space,  disturbance  of  the  perception  of  depth  and  distance,  visual 
attention  loss,  and  visual  agnosia." 

George  Riddoch  as  the  result  of  visual  field  studies  in  cases  of  occi- 
pital injury  has  demonstrated  that  should  recovery  of  vision  occur  in 
restricted  fields  of  vision  the  first  visual  stimulus  perceived,  capable  of 
being  recorded  on  a  chart  as  a  field,  is  movement,  which  begins  in  the 
peripheral  field;  the  field  for  the  appreciation  of  movement,  being  the 
more  primitive  perception,  is  larger  than  the  one  obtained  by  the  re- 
cognition of  a  test  object.  His  observations  also  agree  with  the  con- 
clusions reached  by  Holmes  and  Lister  in  the  cortical  representation 
of  the  retina. 

The  Pupil  in  Hemianopsia. — The  reaction  of  the  pupil  in  hemian- 
opsia has  usually  been  regarded  as  a  localizing  symj)tom  of  importance; 
this  is  denied  by  some  observers  (see  page  571).  (icnerally  the  rules 
are  stated  as  follows: 

If,  in  hemianopsia,  the  light  thrown  upon  either  the  blind  or  the 
seeing  side  of  the  retina  causes  contraction  of  the  pupil,  tlu^  lesion  is 
back  of  the  i)rimary  optic  centers. 

If  there  is  no  contraction  of  the  pupil  when  the  ray  of  light  falls 
ujjon  the  l-)lind  side  of  the  retina,  but  there  is  contraction  when  it  falls 
upon  the  seeing  side,  the  lesion  is  in  front  of  the  primary  optic  centers. 

In  the  foiiiier  iiistuiice  the  lesion  is  so  sitintted  thai  there  is  no  dis- 


OBSCURATION  OF  ONE-HALF  OF  VISUAL  FIELD,  OR  HEMIANOPSIA  571 

turbance  of  the  sensorimotor  arc  of  the  pupils;  in  the  latter  the  lesion 
interferes  with  this  arc,  and  the  pupillary  change  receives  the  name 
hemiopic  or  hendanopic  pupillary  inaction.  It  is  often  called  Wer- 
nicke's symptom.^ 

1  Henschen  (KUn.  med.  anat.  Beitrage  zur  Pathologie  des  Gehims,  Th.  iii)  con- 
cludes that  the  hemiopic  pupillary  inaction  (abbreviated  H.  R.)  is  present  in  tract 
lesions,  even  when  minute  or  merely  caused  by  pressure;  lesions  of  the  posterior 
segment  of  the  thalamus  and  pulvinar — ^perhaps  from  pressure  on  the  tract,  or  by 
destroying  the  brachium  anterius;  lesions  of  the  chiasm  (occasionally  absent  from 
unknown  reasons);  and  in  lesions  of  the  nerve,  with  unilateral  hemianopsia.  It 
is  a  difficult  symptom  to  demonstrate  (Henschen  uses  a  special  lamp)  and  its  ex- 
istence is  doubted  by  some  observers.  The  iris  reaction  may  not  be  entirely  ab- 
sent when  the  ray  falls  on  the  blind  side  of  the  retina,  but  it  is  much  less  marked 
than  the  one  which  follows  light  stimulus  of  the  opposite  side.  C.  B.  Walker 
(Trans.  Section  on  Ophthalmology,  Amer.  Med.  Assoc.  1914)  has  designed  a  clini- 
cal instrument  for  elucidating  the  hemiopic  pupillary  reaction  and  concludes  from 
his  studies  that  it  has  no  topical  diagnostic  value.  To  replace  Henschen's  pheno- 
menon, Wildbrand  has  proposed  a  prism  test.  It  is  thus  described  by  Saenger :  The 
patient  fixes  a  white  point  on  a  large  black  plane  surface.  Suddenly  two  prisms 
of  equal  degree  (15°)  are  brought  before  both  eyes,  their  apices  being  turned  to 
the  hemianopic  defect.  If  cortical  hemianopsia  exists,  the  patient's  eyes  will 
move  so  that  the  fovea  is  directed  to  the  object;  if  the  reflex  path  is  interrupted 
by  a  lesion  of  the  tractus,  there  is  no  movement  of  the  eyes. 


CHAPTER  XIX 
MOVEMENTS    OF  THE  EYEBALLS  AND  THEIR  ANOMALIES 

Anatomy  and  Physiologic  Action  of  the  Ocular  Muscles. — 

The  movements  of  the  eye  are  controlled  by  the  action  of  six  muscles, 
four  straight  and  two  oblique,  in  general  terms  situated  in  the  orbital 
region. 

1.  The  external  rectus  arises  by  two  heads,  respectively  from 
the  outer  margin  of  the  optic  foramen  and  the  common  teiulon  of  the 
inferior  and  internal  recti,  and  in  part  from  a  process  of  bone  on  the 
lower  margin  of  the  sphenoid  fissure.  Its  tendon  is  inserted  into 
the  sclera  7  mm.  from  the  margin  of  the  cornea.  It  is  supplied  by  the 
sixth  or  abducens  nerve.  Its  pre-eminent^  muscular  action  is  abduction — 
that  is,  it  rotates  the  eye  directly  outward. 

2.  The  internal  rectus  arises  from  the  optic  foramen  by  a  tendon 
common  to  it  and  the  inferior  rectus,  and  passes  forward  to  be  inserted 
by  a  tendinous  expansion  into  the  sclerotic  coat  5  mm.  from  the  margin 
of  the  cornea.  It  is  supplied  by  one  of  the  three  l)ranches  of  the  in- 
ferior division  of  the  third  or  oculomotor  nerve.  Its  pre-eminent  mus- 
cular action  is  adduction — that  is,  it  rotates  the  eye  directly  inward. 

3.  The  superior  rectus  arises  from  the  upper  margin  of  the  optic 
foramen  and  from  the  fibrous  sheath  of  the  optic  nerve,  and  is  inserted 
by  a  tendinous  expansion  into  the  sclerotic  coat  8  mm.  from  the  margin 
of  the  cornea.  It  is  supplied  by  the  superior  division  of  the  third  or 
oculomotor  nerve.  Its  pre-eminent  muscular  action  is  elevation  or 
superduction — that  is,  it  rotates  the  eye  upward.  It  also  adducts  it 
and  rotates  the  upper  end  of  the  vertical  meridian  of  the  cornea  in- 
ward {inward  torsion  or  intorsion). 

4.  The  injerior  rectus  arises  from  the  optic  foramen  l)y  a  tenilon 
common  to  it  and  the  internal  rectus  and  passes  forward  to  be  inserted 
by  a  tendinous  expansion  intrrthe  sclerotic  coat,  G  nun.  from  the  margin 
of  the  cornea.  It  is  supplied  l)y  one  of  the  three  branches  of  the  in- 
ferior division  of  the  third  or  oculomotor  nerve.  Its  pre-eminent  nuis- 
cular  action  is  depression,  or  subduction — that  is,  it  rotates  the  (>ve 
downward.  It  also  adducts  it  and  rotates  the  vertical  meridian  of  the 
cornea  outward  (out ward  torsion,  extorsion). 

5.  The  superior  obli(iuc  (trochlear)  is  situated  at  tiie  upper  and  inner 
side  of  the  orbit,  and  arises  al)ove  the  inner  maigin  of  the  optic  foramen. 
It  proceeds  to  the  inner  angle  of  the  orbit,  at  which  point  its  roundeil 
tendon  passes  llirougli  .-i  lil)i<»(;irtilaginous  pulley  occupying  a  fossa 
just  within  the  supra-orbital  margin  of  the  fiontal  bone,  and  is  lu'xt 
reflected  backwaid.  outward,  and  do\vnw:ii(l,  to  be  insertcMl  about  IS 
mm.  t  roiii  I  lie  edge  of  t  lie  cornra  bet  werii  I  lie  superior  and  external  rcct  i. 

''J'liis  Irrin  is  luiiioucd  Irniii    Mmldox. 


KOTATION  OF  THE  EYEBALL  AROUND  THE  VISUAL  LINE      573 

It  is  supplied  by  the  fourth  or  trochlear  nerve.  Its  pre-eminent  muscular 
action  is  intorsion — that  is,  it  rotates  the  vertical  meridian  inward.  It 
also  depresses  the  eye  and  abducts  it  (see  footnote). 

6.  The  inferior  oblique  is  situated  at  the  bottom  of  the  orbit  and 
arises  from  a  depression  in  the  orbital  plate  of  the  superior  maxillary 
bone.  Passing  beneath  the  inferior  rectus,  it  is  directed  outward, 
backward,  and  upward,  and  reaches  its  insertion  into  the  sclera  by 
means  of  a  thin  tendon  about  19  mm.  from  the  corneal  margin,  within 
the  position  of  the  external  rectus.  It  is  supplied  by  the  largest  branch 
of  the  superior  division  of  the  third  or  oculomotor  nerve.  Its  pre-emi- 
nent muscular  action  is  extorsion — that  is,  it  rotates  the  vertical 
meridian  outward.     It  also  elevates  the  eye  and  abducts  it.^ 

The  starting-point  from  which  the  actions  of  the  muscles  are  reck- 
oned is  the  primary  position  of  the  globe,  defined  by  Mauthner  as  that 
position  of  the  eyes  from  which  the  visual  lines  can  be  moved  without 
the  eyes  being  revolved  around  their  anteroposterior  axes.  The  eyes 
occupy  about  this  position  when  they  arc  directed  straight  forward, 
the  head  being  held  erect,  and  a  distant  object,  situated  in  the  median 
line  of  the  visual  plane,  is  observed  with  practically  parallel  visual 
lines.  Positions  of  the  eyes  other  than  this  are  called  secondary 
positions. 

Rotation  of  the  Eyeball  Around  the  Visual  Line. — If  a  vertical 
line  is  passed  through  the  visual  line  so  as  to  divide  the  eyeball  into  two 
lateral  halves,  it  will  intersect  the  surface  of  the  ej^eball  in  what  is  called 
the  vertical  meridian.  The  latter  may  be  defined  with  sufficient 
accuracy  as  a  line  passing  through  the  center  of  the  pupil  in  a  direction 
perpendicular  to  the  line  joining  the  centers  of  the  two  pupils.  It  joins 
the  uppermost  and  lowermost  points  of  the  corneal  margin. 

In  movements  of  the  eyeball  directly  upward  (combined  action  of 
the  superior  rectus  and  inferior  oblique)  or  downward  (combined  action 
of  the  inferior  rectus  and  superior  oblique),  or  directly  inward  or  out- 
ward, the  vertical  meridian  remains  vertical. 

In  oblique  movements  of  the  eyeball,  upward  and  inward  (superior 
and  internal  rectus,  with  inferior  obliqye) ;  downward  and  inward 
(inferior  and  internal  rectus,  with  superior  oblique) ;  upward  and  out- 
ward (superior  and  external  rectus,  with  inferior  oblique) ;  or  down- 
ward and  outward  (inferior  and  external  rectus,  with  superior  oblique), 
the  vertical  meridian  will  be  observed  to  rotate  like  the  spokes  of  a 
wheel  {wheel-rotation  or  torsion) .  The  eyeball  appears  to  rotate  around 
the  visual  line ;  this  is  effected  by  the  superior  and  inferior  recti  and  the 
superior  and  inferior  oblique  muscles.  The  upper  extremity  of  the 
vertical  meridian  of  the  cornea  is  deviated  outward  (toward  the  temple) 
by  the  inferior  recti  and  inferior  oblique  muscles;  and  inward  (toward 
the  nose)  by  the  superior  recti  and  superior  oblique  muscles.     The 

1  Duane,  basing  his  opinion  on  the  results  of  paralysis,  believes  that  depression 
is  the  most  important  muscular  action  of  the  superior  oblique  and  that  elevation 
is  the  most  important  action  of  the  inferior  oblique,  intorsion  and  extorsion,  re- 
spectively, being  subsidiary  actions. 


574   MOVEMENTS   OF   THE   EYEBALLS   AND   THEIR   ANOMALIES 

deviation  of  the  vertical  meridian  produced  bj'  any  muscle  is  greatest 
when  the  axis  of  rotation  for  that  muscle  coincides  with  the  visual  hne. 

The  superior  and  inferior  recti  exercise  the  greatest  degree  of  torsion 
when  the  eyeball  is  drawn  toward  the  nose,  and  either  upward  or 
downward. 

The  oblique  muscles,  on  the  contrary,  exercise  their  maximum 
amount  of  torsion  when  the  eyeball  is  drawn  toward  the  temple,  and 
either  upward  or  downward.  The  inferior  oblique,  while  it  aids  the 
superior  rectus  in  upward  movements,  antagonizes  it  in  the  rotation 
of  the  vertical  meridian  and  the  movement  of  the  eyeball  inward. 

The  visual  line  coincides  most  nearl}-^  with  the  axis  of  rotation  of  the 
superior  and  inferior  recti  when  the  ej'eball  is  drawn  toward  the  nose 
and  most  nearly  with  that  of  the  superior  and  inferior  oblique  muscles 
when  the  eyeball  is  turned  toward  the  temple.  The  superior  oblique 
aids  the  inferior  rectus  in  drawing  the  eye  downward,  but  antagonizes 
it  in  the  rotation  of  the  vertical  meridian  and  in  the  movement  of  the 
eyeball  inward. 

In  extreme  diagonal  movements  of  the  eyes  the  action  of  the  ob- 
liques and  the  recti  is  to  make  the  vertical  meridian  tilt  toward  the  nose 
or  temple.  But  if  the  muscles  are  evenlj--  balanced,  the  vertical 
meridians  of  the  two  eyes,  however  tilted,  remain  parallel,  and  under 
these  conditions  the  retinal  images  are  projected  normally,  vertical 
objects  still  appearing  vertical.  According  to  Sherrington  our  notions 
of  the  verticality  of  the  objects  are  dependent  not  only  on  visual  but 
on  other  sensory  impressions. 

In  paralysis  of  the  eye  muscles  the  vertical  meridians  no  longer 
remain  parallel,  and  the  image  of  one  eye  appears  oblique  with  regard 
to  the  other.     (See  also  page  579.) 

Associated  Movements. — Except  in  pathologic  circumstances, 
there  is  coordination  in  the  movements  of  the  eyes,  and  the  movement 
of  one  eyeball  is  associated  with  that  of  its  fellow.  In  other  words,  both 
eyes  are  used  for  seeing  {binocular  visi07i),  and  are  so  adjusted  that  the 
image  of  the  object  regarded  falls  simultaneously  on  both  maculas 
(binocular  fixation).  If  a  distant  object  is  to  be  looked  at  and  the  right 
eye  is  turned  to  the  right,  the  left  eye  is  also  turned  to  the  right  and  to 
the  same  extent  as  its  fellow,  because  of  the  associated  action  of  the  ex- 
ternal rectus  of  the  right  eye  and  the  internal  rectus  of  the  loft  eye 
under  tiie  same  innervation-impulse.  If  one  eye  is  elevated,  the  other 
is  also  elevated;  if  one  is  depressed,  the  other  is  also  depressed.  These 
are  associated  movements  in  the  same  direction. 

If  a  near  object  is  to  be  looked  at,  the  visual  axes  converge  iov  the 
point  at  which  it  is  situated  because  of  the  a.ssoi-iated  action  of  (he 
internal  recti  of  the  two  eyes  {convergence  or  accomtnmiative  movement) ; 
if  the  eyes  are  removed  from  this  point  and  directed  to  a  distant  ob- 
ject, the  visual  axes  tend  to  p:ir;ill('lism  because^  of  the  action  of  lioth 
external  recti. 

If  the  associated  movcniciits  of  the  eves  were  not  thus  ri'gulated  by 
equal  impulses  from  the  coordinating  center,  single  vision  would  not 


•ASSOCIATED  MOVEMENTS  575 

be  possible,  because  the  images  of  any  object  would  not  fall  upon 
corresponding  points  of  the  two  retinas.  Inasmuch  as  every  normal 
individual  has  two  normally  constructed  eyes,  he  must  receive  from 
every  object  two  sets  of  sensations,  which  are  blended  into  one  when 
the  movements  of  the  eyes  are  so  arranged  that  the  images  fall  upon 
corresponding  retinal  areas. 

A  point  situated  anywhere  upon  the  right  side  of  one  retina  has  its 
corresponding  point  upon  the  right  side  of  the  other  retina,  and  points 
on  the  left  side  of  one  correspond  with  points  on  the  left  side  of  the 
other.  The  upper  haK  of  the  retina  of  the  right  eye  corresponds  to  the 
upper  half  of  the  retina  of  the  left  eye,  and  the  lower  half  of  the  right  to 
the  lower  half  of  the  left;  the  nasal  side  of  the  right  eye  corresponds  with 
the  malar  side  of  the  left,  and  the  malar  of  the  right  with  the  nasal  of 
the  left.  If,  for  any  reason,  the  movements  of  the  eyes  become  dis- 
arranged so  that  the  images  do  not  fall  upon  corresponding  or  identical 
retinal  areas,  the  images  become  double. 

The  desire  for  binocular  single  vision,  or  single  vision  with  the  two 
eyes,  which  depends  upon  the  blending  of  the  two  sets  of  sensations,  or, 
as  it  is  also  called,  fusion,  is  believed  to  be  the  origin  of  the  impulse 
which  directs  the  movements  of  the  eyeballs,  especially  in  association 
in  the  same  direction. 

In  addition  to  this  desire  for  blending  the  two  sets  of  sensations  into 
one,  seen  in  the  associated  movements  of  the  eyes  in  the  same  direction, 
there  is  also  another  regulating  factor — i.  e.,  the  connection  between 
convergence  and  accommodation  (see  page  44). 

Overcoming  Prisms. — When  a  prism  is  placed  before  one  eye  with 
its  base  inward  and  diplopia  is  produced,  an  outward  rotation  of  the  eye 
occurs,  and  when  the  prism  is  placed  with  its  base  outward,  an  inward 
rotation  of  the  eye  takes  place,  and  the  influence  of  the  prism  is  over- 
come, so  that  single  vision  again  is  possible  within  the  limitations  which 
have  been  recorded  on  page  76,  where  prism-convergence,  prism- 
divergence,  and  sursumvergence  are  described. 

Field  of  Fixation. — This  includes  all  points  which  the  eye  under 
observation  can  successively  fixate,  the  head  being  perfectly  station- 
ary. The  field  of  fixation  of  an  amblyopic  eye  may  be  determined  by 
watching  the  image  of  a  candle-flame  on  the  center  of  the  cornea  as  the 
eye  follows  the  test-light  moved  along  the  perimeter  arc  until  the  limit 
of  movement  is  reached.  Ordinarily  the  patient  should  be  seated  in 
the  position  for  testing  the  visual  field  before  the  perimeter,  with  the 
semicircle  horizontal,  and  the  eye  (the  head  being  rigid)  made  to  follow 
a  word  composed  of  small  test-letters,  and  the  point  where  vision  ceases 
to  be  distinct  marked  on  successive  meridians.  In  place  of  letters, 
two  fine  dots  set  close  together  on  a  card  may  be  employed,  and  the 
point  noted  where  the  dots  cease  to  appear  as  two. 

Landolt's  measurements  of  the  field  of  fixation  under  normal  condi- 
tions are  as  follows:  Outward,  45-50;  inward,  45;  upward,  35-40; 
downward,  60.  Duane's  average  measurements  are:  Outward,  51; 
inward,  53;  upward,  43;  downward,  63. 


576    MOVEMENTS    OF   THE    EYEBALLS    AND    THEIR    ANOMALIES 

G.  T.  Stevens  determines  the  rotations  of  the  eyes  with  a  special 
instrument  called  a  tropomcter.  According  to  him,  the  most  favorable 
rotations  are:  Outward,  50;  inward,  50;  upward.  33;  downward.  50. 

Strabismus,  Squint,  or  Heterotropia.— Under  the  troneral  term 
strabi.stnuii  or  sijuint  are  included  those  conditions  which  (K-cur  when 
the  visual  axis  of  one  eye  is  deviated  from  the  point  of  fixation.  The 
eye  the  visual  axis  of  which  is  directed  to  the  object  fixated  is  termed 
the  fixing  {fi.xatimj)  eye;  the  other  eye  is  termed  the  squinting  or  deviating 
eye.  The  deviation  may  be  inward  (strabitimus  convergen.s) ,■  outward 
(strabismus  divergens),  upward  {strabismus  sursum  lergens),  or  down- 
ward {strabismus  dear  sum,  ver  gens). 

1.  Convergent  Strabismus,  or  Esotropia.— In  this  form  of  squint 
the  visual  line  of  oii(>  eve  is  direclcd  to  the  object  fixed.     The  visual  line 


Fio    246. — ("oiivorMoiit   strahisiims.      Position    and    i>rojfction    of    tin-    iniani-s    (.lames 

Wallace). 
TliiH  (JiuKriim  iiIho  illuHtriitc-s  the  prinriplr  of  r^uioiKi/  excluoUm.     If.  in  the  cBdopiotun-d   there 
JM  H.iuiiit  with  HupprcHsioii  thi-n  iK.onlii.K  to  this  principle  as  iMiuncmt.><l  by  von  Cracfo.  ""«  ""'y 
is  the  arrow  (the  iniaKC- of  whi.h  falin  on   thr  riRht    n.a.uhi, /')  not  seen  by  the  left  oyc    but   the 
candle  (the  imago  of  which  falin  on  the  macula  of  the  left  eye)  ih  not  perceive.!  by  the  riRhl  eye. 

of  the  other  eye  is  deviated  inward,  and  intersects  that  of  the  .^ouiid  eye 
at  some  point  nearer  lh;iii  the  object  fixed.  The  iniaj^e  of  an  <»l)ject 
situated  on  the  visiml  line  of  this  e>c  would  I'c  t'onncd  on  the  lovt>a, 
;in<l   pidjected   lo  tile  same  |)oilit    ill   llie  Held  ol    tixatioil. 


STRABISMUS,    SQUINT,     OR    HETEROTROPIA 


577 


Figure  246  represents  a  convergent  squint  of  the  left  eye,  and  serves 
to  explain  the  results  of  an  inward  deviation  of  one  eye  from  any  cause. 

The  center  of  rotation  is  seen  at  r.  The  arrow  is  the  object  fixated ;  its  image  is 
formed  on  the  fovea  of  the  right  eye,  Fi,  and  its  position  in  the  field  is  denoted  by 
/i.  The  candle  forms  its  image  on  the  retina  of  the  right  eye  to  the  left  of  the  fovea 
at  //;  its  image  is  properly  projected  to  the  right,  and  its  position  in  the  field  is 
denoted  by  h.  The  visual  axis  of  the  left  eye  is  directed  to  the  candle ;  its  image  is 
formed  on  the  fovea  at  F^i,  and  its  position  in  the  field  is  denoted  by  f-<,  identical 
with  that  Oif  /i,  because  formed  on  an  identical  point  of  the  retina.  The  arrow 
forms  an  image  on  the  retina  of  the  left  eye  at  G,  to  the  right  of  the  fovea;  it  is  con-- 
sequently  projected  to  the  left  of  that  of  F2,  and  its  position  in  the  field  is  denoted 
by  g. 

The  right  eye  projects  the  images  correctly;  the  left  eye  projects 
them  to  the  left  of  their  true  position — i.  e.,  to  the  side  of  the  squinting 
eye.     The  diplopia  is  simple  or  homonymous. 

2.  Divergent  Strabismus,  or  Exotropia. — In  this  form  of  squint 
the  visual  line  of  one  eye  fixates  the  object,  while  the  visual  line  of  the 


Fig.   247. — Divergent    strabismus.      Position    and    projection    of    the    images    (Jamea 

Wallace). 

other  eye  lacks  the  necessary  movement  inward  to  intersect  that  of  its 
fellow  at  the  point  of  fixation. 

A.S  long  as  the  visual  axis  of  the  affected  eye  intersects  that  of  the 

sound  eye  in  its  anterior  extremity,  the  affection  may  be  denominated 

insufficiency  of  convergeiice.     When  the  visual  axes  no  longer  intersect 

anteriorly,  but  diverge  from  each  other  so  that  their  posterior  extremit 

37 


578   MOVEMENTS   OF   THE   EYEBALLS   AND   THEIR   ANOMALIES 


ties  intersect,  the  affection  may  bo  denominated  divergent  squint.  If 
the  convergence  insufficiency  is  considerable,  so  that  the  visual  axes 
do  not  intersect  at  the  ordinary  reading  distance,  although  they  do 
intersect  anteriorly,  the  condition  is  denominated  by  many  as  a 
directly  periodic  divergent  squint.  On  the  other  hand,  there  are  not  a 
few  cases  in  which  the  axes  diverge  at  their  anterior  extremities  but 
intersect  at  the  reading  distance.  These  may  be  denominated  cases 
of  inversely  periodic  divergent  squint,  being,  in  fact,  due  to  a  con- 
dition of  marked  divergence  excess  (Duane). 

Figure  247  represents  a  divergent  squint  of  the  left  eye,  and 
explains  the  effects  of  an  outward  deviation  of  one  eye  from  any  cause 
upon  the  position  of  the  images  of  an  object  which  is  fixated. 


FiO.   248. — Coiiver>.'eiit  sti'al)isinus  with  dccitleti  upward  deviation  (.from  ii  p.itient  in  th« 
Philadelphia  (Joueral  Hospital). 

Tlie  center  of  rotation  is  at  r.  The  arrow  i.s  tlie  object  fixed ;  its  image  is 
formed  on  the  fovea  of  tlie  ri^lit  eye  at  b\,  and  its  position  in  tlie  field  is  denoted  by 
/i.  The  candle  forms  its  iniane  on  tlie  retina  of  the  rinht  eye  to  the  ri^ht  of  the 
fovea  at  //;  its  ima^e  is  properly  projected  to  the  left  and  its  position  in  the  field 
is  denoted  l)y  h.  The  visual  axis  of  the  left  eye  is  directed  to  the  camile;  it^  image 
is  formed  on  the  fovea  at  /''.•,  and  its  position  in  the  field  denoted  by  /i,  identical 
with  that  of  /i,  because  formed  on  identical  point.s  of  the  retina.  The  arrow 
forms  an  imaiie  on  the  retina  of  the  left  «'ye  at  (1,  to  the  left  of  the  fovea;  it  is  con- 
sequently proj«'cted  to  tlie  right  of  that  of  /''•..  and  its  position  in  the  field  is  denoted 


STRABISMUS,  SQUINT,  OR  HETEROTROPIA  579 

The  right  eye  projects  the  images  properly:  the  left  eye  projects 
them  to  the  right  of  their  true  position — i.  e.,  the  side  opposite  to  the 
squinting  eye.     The  diplopia  is  crossed  or  heteronymous. 

3.  Upward  and  Downward  Squint,  or  Hypertropia. — If  vertical 
deviation  (upward  or  downward)  causes  diplopia,  the  images  are  on 
different  levels,  the  upper  image  corresponding  with  the  lower  eye. 
Simple  vertical  deviation  without  lateral  is  rare.  Generally  in  lateral 
strabismus  the  squinting  eye  deviates  upward,  but  may  also  turn 
downward  (Schweigger).  According  to  Hansell,  functional  internal 
squint  (esotropia)  is  always  associated  with  upward  deviation  (hyper- 
tropia). In  deviations,  especially  when  there  is  vertical  squint,  one  of 
the  images  is  often  oblique  with  regard  to  the  other. 

This  obhquity  can  be  simplified  for  study  by  dividing  it  into  two 
kinds:  either  the  vertical  meridians  incline  toward  each  other  by  their 
upper  extremities,  or  else  they  diverge  from  each  other. 

The  meridians  diverge  from  each  other  when  the  upper  extremity 
of  one  vertical  meridian  is  directed  toward  the  temple, while  the  vertical 
meridian  of  the  other  eye  remains  perpendicular.  If  the  two  eyes  are 
sighting  an  upright  object,  like  a  candle,  the  latter  will  form  a  ver- 
tical inverted  image  on  the  retina  of  each.  In  the  eye  whose  vertical 
meridian  remains  perpendicular,  this  image  will  coincide  with  that 
meridian.  In  the  eye  whose  meridian  is  tilted  toward  the  temple, 
the  image  will  fail  to  coincide  with  the  vertical  meridian,  the  lower 
image  of  the  candle  flame  lying  below  the  macula  and  somewhere  on 
the  temporal  half  of  the  retina,  and  the  image  of  the  candle  base 
lying  upon  the  macula  and  somewhere  on  the  nasal  half  of  the 
retina.  In  accordance  with  the  law  of  projection,  images  on  the  nasal 
half  of  the  retina  are  referred  to  the  temporal  portion  of  the  field, 
and  images  on  the  temporal  half  of  the  retina  are  referred  to  the  nasal 
portion  of  the  field.  With  the  vertical  meridian  tilted  toward  the  temple 
the  candle  forms  an  image  on  the  retina  which  is  projected  outward, 
so  that  it  seems  to  converge  by  its  upper  extremity  toward  that  of  the 
other  eye  when  the  diplopia  is  homonymous;  when  crossed  diplopia 
exists,  it  seems  to  diverge. 

The  meridians  converge  toward  each  other  when  the  upper  extermity 
of  one  vertical  meridian  is  tilted  toward  the  nose,  while  the  vertical 
meridian  of  the  other  eye  remains  perpendicular. 

When  the  vertical  meridian  is  tilted  toward  the  nose  by  its  upper 
extremity,  the  image  of  the  candle  occupies,  with  its  lower  portion,  a 
point  in  the  nasal  half  of  the  retina,  and  with  its  upper  portion  a  point 
in  the  temporal  half  of  the  retina.  It  is  projected  outward  in  such  a 
manner  that  it  seems  to  lean  away  from  the  image  of  the  other  eye  when 
the  diplopia  is  homonymous;  when  crossed  diplopia  exists,  it  seems  to 
lean  toward  the  image  of  the  other  eye. 

In  paralysis  of  the  ocular  muscles  it  is  usually  the  image  of  the 
paralytic  eye  which  appears  oblique.  Sometimes,  however,  the  patient 
regards  this  image  as  vertical  and  the  image  of  the  sound  eye  as 
obUque  (see  also  pages  573  and  574). 


580    MOVEMENTS   OF   THE    EYEBALLS   AND   THEIR    ANOMALIES 

Paralysis  of  the  Exterior  Ocular  Muscles  iJ\irabjtic  Strabismus) . 
This  may  he  complete  (the  musclo  is  ontiroly  paralyzed)  or  incomplete 
(the  muscle  is  partially  paralyzed). 

A.  General  Symptoms. — Certain  symptoms  are  common  to  paraly- 
sis of  the  exterior  eye  muscles. 

1.  Loss  of  Binocular  Single  Vision,  or  Diplopia. — The  cause  of  this, 
evident  from  the  previous  explanations,  depends  upon  the  deviation 
of  the  affected  eye  so  that  the  images  from  an  object  are  no  longer 
fused,  owing  to  their  failure  to  fall  upon  "identical  points"  in  the  two 
retinas.  Diplopia  increases  as  the  object  is  moved  to  the  side  of  the 
paralyzed  muscle.  In  slight  degree  it  amounts  only  to  indistinct 
vision. 

2.  N on-correspondence  of  the  Direction  of  the  Two  Eyes,  or  Strabis- 
mus.— This  depends  upon  the  deviation  to  which  the  affected  eye  is 
subjected  by  the  tone  of  the  unresisted  action  of  the  muscle  which  is 
the  antagonist  of  the  paralyzed  muscle,  and  also,  in  part,  upon  the 
effect  of  secondary  contractures.  Squint  is  not  always  plainly  mani- 
fest, and  may  appear  only  if  an  attempt  is  made  to  move  the  eye  in  the 
direction  of  the  action  of  the  palsied  muscle. 

3.  Loss  or  Limitation  of  Movement  (Primary  Deviation). — The  limi- 
tation of  movement  is  always  in  the  direction  of  the  action  of  the 
affected  muscle;  consequently'  the  deviation  of  the  eye  is  in  a  direction 
opposite  to  the  action  of  the  muscle. 

4.  Deviation  of  the  Soiind  Eye,  While  the  Affected  EyeFixaies  (Second- 
ary Deviation). — During  the  act  of  fixation  by  the  affected  eye  the  same 
degree  of  nervous  impulse  passes  from  the  center  to  the  muscles  of  the 
affected  eye  and  to  those  of  its  non-affected  associate;  the  former  re- 
quires an  abnormally  great  impulse  to  stimulate  its  movement,  and 
hence  the  latter  is  overexcited,  and  the  resulting  movement  is  exces- 
sive. The  secondary  deviation,  therefore,  is  greater  than  the  primary 
deviation. 

In  order  to  demonstrate  this  the  sound  e\'e  is  covered  with  the  hand, 
while  the  affected  eye  is  directed  toward  an  object  held  at  a  distance  of 
about  one  foot.  The  covering  hand  is  then  moved  from  the  sound  to 
the  affected  eye.  In  order  to  fixate  the  object,  the  sound  eye  nuist  now 
move  in  a  direction  opposite  to  that  towartl  which  the  paralyzed  nuisde 
rotates  the  ball.  This  backward  movement  represents  the  degree  of 
previous  excess  called  into  existence  by  the  undue  amount  of  nerve- 
force  which  the  noiinal  nuiscle  originally  received.  Thus  primary  and 
secondary  deviations  are  in  ()p])osite  direct  ion,  l)Ut  botii  in  the  lin(>  of 
action  of  the  affected  nuiscle. 

5.  False  Projection  of  the  Fidd  of  Vision.-  This  (IcpciHls  u|)on  an 
inaccurate  estimation  of  the  position  of  an  object  situated  in  such  a 
portion  of  the  visual  field  that  it  re(|uires  an  effort  on  the  pait  of  the 
affected  nuiscle  to  tiiiii  tlic  eye  towaid  it.  A  noinial  individual  (his 
head  being  stationar>,  and  one  eye  being  closed,  <.  y.,  the  rights  can 
readily  and  accurately  touch  an  oltject  lying  witiiin  iiis  reach  to  the  left 
of  the  median  line,  because  the  degree  of  innervjit ion  recjuired  t«>  mak«' 
the  lateral  movement  of  the  eye  in  oriler  to  see  the  object  gives  ti»e 


PARALYSIS    OF    THE    EXTERIOR    OCULAR    MUSCLES  581 

necessary  information,  based  on  experience,  how  far  to  the  left  the  ob- 
ject Hes.  In  the  same  circumstances  an  individual  with  a  paretic  left 
external  rectus,  instead  of  touching  the  object,  would  pass  his  hand 
beyond  it — i.  e.,  to  the  left  of  it,  because  the  excessive  innervation 
which  is  now  necessary  to  make  the  lateral  turn  gives  the  impression 
that  the  object  lies  farther  to  the  left.  In  other  words,  the  object  is 
projected  to  a  position  in  the  visual  field  which  it  does  not  have. 

6.  Vertigo. — This  depends,  both  eyes  being  open,  upon  the  diplopia 
and  the  confusion  arising  from  trying  to  distinguish  between  the  real 
and  the  false  image.  If  one  eye  (the  unaffected  eye)  is  closed,  it  de- 
pends upon  the  condition  described  in  the  preceding  paragraph. 

In  a  paretic  condition  of  the  muscles  which  rotate  the  eye  down- 
ward vertigo  may  result  from  an  erroneous  localization  of  objects  in 
the  lower  field,  as  they  seem  to  lie  in  a  plane  deeper  than  they  really  are. 
For  these  reasons  patients  with  ocular  palsies  commonly  close  the 
affected  eye,  although  closure  of  either  eye  would  remove  the  diplopia. 

7.  Altered  Position  of  the  Carriage  of  the  Head. — This  depends  upon 
the  impulse  of  the  patient  to  carry  his  head  in  that  direction  in  which 
he  is  least  troubled  by  the  double  images,  and  this  is  usually  in  the 
direction  toward  which  the  affected  muscle  moves  the  eye.  In  vertical 
deviation  the  head  is  often  tilted  toward  one  shoulder — toward  the  side 
of  the  higher  eye  if  the  hyperphoria  or  hj-pertropia  is  combined  with 
crossed  diplopia,  and  toward  the  other  side  if  the  hyperphoria  or  hy- 
pertropia  is  combined  with  homonymous  diplopia. 

B.  Varieties  of  Diplopia. — There  are  two  kinds  of' diplopia,  called 
lateral  (horizontal)  and  vertical,  according  as  the  images  are  separated 
laterally  or  vertically.  If,  when  the  images  are  separated  laterally, 
the  right  image  pertains  to  the  right  eye,  and  the  left  image  to  the  left 
eye,  the  diplopia  is  designated  simple  or  homonymous;  if  the  right  image 
pertains  to  the  left  eye,  and  the  left  image  to  the  right  eye,  the  diplopia 
is  named  crossed  or  heteronymous.  The  explanation  of  these  conditions 
has  been  given  (see  Figs.  246  and  247). 

C.  Special  Symptoms. — The  following  paragraphs  contain  the  most 
important  symptoms  peculiar  to  paralysis  of  individual  muscles.  For 
convenience  it  is  supposed  that  the  right  eye  is  affected. 

1.  External  Rectus. — The  following  phenomena  may  be  present: 
(a)  Lateral  homo7iymous  diplopia,  the  images  being  side  by  side 
and  parallel,  if  the  eyes  are  directed  on  a  horizontal  level,  the  distance 
between  them  widening  as  the  test-object  is  moved  to  the  right — that 
is,  the  maximum  diplopia  is  to  the  right  (Fig.  249). 

If  the  test-object  is  moved  to  the  right  and  above,  and  the  eyes  are 
directed  toward  it,  the  false  image  (image  of  the  right  or  affected  eye) 
diverges  from  the  real  image  (image  of  the  left  or  unaffected  eye). 
This  occurs  because,  in  these  circumstances,  the  movement  of  the  right 
eyeball  toward  the  temple  is  limited  by  the  feeble  external  rectus,  and 
the  eyeball  fails  to  come  into  the  position  where  the  inferior  oblique  has 
its  favorable  condition  for  rotating  the  vertical  meridian  outward; 
hence  the  vertical  meridian  remains  near  to  a  perpendicular,  while  that 


582    MOVEMENTS   OF   THE    EYEBALLS   AND   THEIR   ANOMALIES 

of  the  sound  eye  is  tilted  toward  it.  There  is  divergence  of  the  vertical 
meridians  (the  false  image  converges  toward  the  real  one)  when  the 
eyes  are  directed  downward  and  toward  the  right,  because  the  eyeball 
fails  to  come  into  a  favorable  position  to  have  its  vertical  meridian 
tilted  toward  the  nose  by  the  superior  oblique,  while  that  of  the  other 
eye  is  tilted  toward  the  temple  by  the  inferior  rectus. 

(h)  Convergent  strabismus,  which  increases  as  the  eye  attempts  to 
follow  an  object  which  is  moved  toward  the  right,  during  which  it  will 
be  noticed  that  there  is  limitation  of  mxyvement  in  this  direction. 


Fig.  249. — A,  Position  of  images  in  paralysis  of  left  external  rectus,  and  B,  in 
of  right  externus.     The  false  image  is  drawn  in  outline  (after  Fiichs). 


d  B,  in  paralysis 


(c)  The  secondary  deviation  of  the  sound  eye  is  inward;  the  Jahe 
'projection  of  the  field  of  vision  is  to  the  right  side,  and  the  face  is  turned 
to  the  right — i.  e.,  to  the  side  of  the  affected  muscle. 

2.  Internal  Rectus. — There  are  present: 

(a)  Lateral  crossed  diplopia,  the  images  being  side  by  side  and 
parallel,  if  the  eyes  are  directed  along  a  horizontal  level,  the  distance 
between  them  widening  as  the  test-object  is  moved  to  the  left,  or  if  the 
eyes  are  directed  upward — that  is,  the  maximum  diplopia  is  to  the 
left  (Fig.  250). 

If  the  test-object  is  moved  to  the  left  and  above,  and  the  eyes  are 
directed  toward  it,  the  image  of  the  affected  eye  is  lower  than  that  of 


Fig.   250. — A,  Position  of  ini;if.'is  in  purulysis  of  left  inifrnal  loiu.s,  ami  B,  in  paralysis 
of  right  iuternus.     The  false  imago  is  drawn  in  outline  (.after  Fuchs). 

the  unaffected  eye,  and  its  upper  extremity  inclines  toward  it;if  thetest- 
object  is  moved  to  the  left  and  downwarti,  the  false  image  is  higher  antl 
its  lower  extremity  inclines  away  from  that  of  the  real  image.  These 
inclinations  occur  because,  in  these  circumstances,  the  left  eyeball  is 
placed  in  a  favorable  position  for  one  of  the  oblique  muscles  to  rotate  it, 
while  the  right  eye  is  not  brought  in  sufficiently  for  the  superior  or 
inferior  rectus  to  exerci-se  its  torsion  elTecl ;  coiiseciuenlly,  the  vertical 
meridians  diverge  on  looking  upwaid  and  converge  on  looking  down- 
ward toward  the  left  side. 


PARALYSIS    OF    THE    EXTERIOR    OCULAR    MUSCLES 


583 


(6)  Divergent  strahismus,  which  increases  when  the  eye  attempts  to 
follow  an  object  moved  to  the  left,  during  which  it  will  he  noticed  that 
there  is  limitation  of  movement  in  this  direction. 

(c)  The  secondary  deviation  of  the  sound  e3'e  is  outward,  the  false 
projection  of  the  visual  field  is  to  the  left  side,  and  the  face  is  turned  to 
the  left — i.  e.,  to  the  side  of  the  affected  muscle. 

3.  Superior  Rectus. — There  are  present: 

(a)  Vertical  crossed  diplopia  in  the  upper  field,  the  images  being  one 
above  the  other,  the  image  of  the  affected  eye  being  higher  than  its 


Fig.   251. — A,  Position  of  images  in  paralysis  of  left  superior  rectus,  and  B,  in  paralysis  of 
right  superior  rectus  (Fuchs). 

fellow  and  inclined  to  the  left  (healthy  side),  and  the  vertical  distance 
between  them  (difference  in  height)  widening  as  the  test-object  is 
moved  upward  and  to  the  right — that  is,  there  is  maximiun  diplopia  in 
looking  up  and  to  the  right  (Fig.  251). 

If  the  test-object  is  moved  upward,  and  to  the  left,  and  the  eyes  are 
directed  toward  it,  the  obliquity  of  the  images  increases — i.  e.,  the  false 
image  is  still  more  inclined  toward  the  sound  side,  away  from  that  of 
the  other.  This  occurs  because,  in  these  circumstances,  the  inferior 
oblique  rotates  the  vertical  meridian  of  the  sound  eye  to  the  left,  while 


Fig.  252. — J.,  Position  of  images  in  paralysis  of  left  inferior  oblique,  and  B,  in  paralysis 
of  right  inferior  oblique  (after  Fuchs). 

the  affected  eye,  owing  to  the  loss  of  power  in  the  superior  rectus,  is 
unable  to  deviate  its  vertical  meridian  from  the  perpendicular;  there- 
fore the  two  meridians  diverge,  but,  the  diplopia  being  crossed,  the 
images  also  diverge. 

(b)  Downward  strabismus,  which  increases  when  the  eye  attempts  to 
follow  an  object  moved  upward,  especially  upward  and  outward, 
during  which  it  will  be  noticed  that  there  is  limitation  of  movement  in 
this  direction. 


584   MOVEMENTS   OF   THE    EYEBALLS   AND   THEIR    ANOMALIES 

(c)  The  secondary  deviation  of  the  sound  eye  is  upward,  the  false 
projection  of  the  visual  field  is  too  high,  and  the  face  is  directed  upward 
and  to  the  right,  or  the  head  is  tilted  toward  one  shoulder,  generally  the  left. 

4.  Inferior  Oblique.— There  are  present : 

(a)  Vertical  hunionynious  diplopia  {so7netimes  crossed)  in  the  upper 
field,  the  images  being  one  above  the  other,  the  image  of  the  affected 
eye  being  higher  than  its  fellow  and  inclined  to  the  right — i.  e.,  to  the 
affected  side — the  vertical  distance  Ix'tween  them  (^difference  in  height) 
widening  as  the  test-object  is  moved  upward  and  to  the  left — that  is, 
there  is  maximum  diplopia  on  looking  up  and  to  the  left. 

If  the  test-object  is  moved  upward  and  to  the  right  and  the  eyes  are 
directed  toward  it,  the  obliquity  of  the  images  increases — i.  e.,  the  false 
image  is  still  more  inclined  away  from  the  souiul  side.  This  occurs 
because,  in  these  circumstances,  the  vertical  meridian  of  the  right  eye 
is  not  tilted  toward  the  temple,  owing  to  loss  of  power  in  the  infe- 
rior oblique,  while  that  of  the  left  eye  is  tilted  toward  the  nose  by  the 


Fig.   253. — A,  Position  of  images  in  paialys's  of  loft  inferior  rectus,  and  B,  in  paralysis  of 
right  inferior  rectus  (after  Fuchs). 


superior  rectus,  now  in  its  best  position  for  tilting  the  vertical  meridian 
inward;  therefoi-e  the  two  meridians  iiicliiu'  toward  each  otlior  by  their 
upp(!r  extremities. 

(b)  Tiie  direction  of  the  affected  eye  is  downward  anil  inward,  which 
is  more  noticeable  when  the  eye  attempts  (o  follow  an  ol)ject  moved 
upward  and  inward,  during  wiiich  it  will  he  noticed  that  there  is 
limitation  of  movement  in  this  dii-ectioii. 

(c)  Tlie  secondary  dcrialioN  of  the  sound  eye  is  upwai'd  and  inwaril, 
the  f(dse  projection  of  the  visual  field  is  too  far  upwar<l,  and  tlie/('cc  is 
directed  upward  and  toward  the  left,  or  the  head  is  tilted  toward  one 
shoulder. 

5.  Inferior  Rectus.-  Tliei-e  are  present  : 

(a)  Wriinil  crossed  diplopia  in  the  lower  field,  (he  images  being  one 
above  the  other,  the  iiii;ia,e  of  tlie  ;il'tcct cd  e\-e  being  lower  than  its 
fellow  and  iiicHiied  to  the  riiilit  /.  <.,  to  I  lie  alTeelecl  side  ;iiid  t  h(> 
vertical  dist;iiice  liclwceii  them  (dirt'ereiice  in  hei^iht  I  widening  as  the 
test-object  is  moved  downward  and  to  the  right  that  is,  there  is 
inaxiinuni  diplopia  on  looking  down  and  to  the  right. 
"■  H  the  test-object  is  iiioxed  downward  and  to  the  left,  and  the  eyes 
are  directed  tow;ird  it,  t  he  oMiquil.N'  <»f  t  he  images  iiicre;i>es      /.  c.tlie 


PARALYSIS    OF    THE    EXTERIOR    OCULAR    MUSCLES     '       585 

false  image  inclines  still  more  toward  the  affected  side.  This  occurs 
because,  in  these  circumstances,  the  superior  oblique  of  the  left  eye  is 
in  its  best  position  for  rotating  the  vertical  meridian  toward  the  nose; 
but  the  right  eye,  by  reason  of  its  paralj^  zed  inferior  rectus,  is  unable  to 
tilt  its  vertical  meridian  to  correspond;  therefore  the  vertical  meridian 
of  the  right  eye  remains  perpendicular,  while  that  of  the  left  eye  inclines 
toward  it.  The  image  of  the  right  eye  seems  to  be  the  oblique  one;  the 
images  diverge,  but,  the  diplopia  being  crossed,  they  seem  to  converge. 

(6)  L'pward  strabismus,  which  increases  when  the  eye  attempts  to 
follow  an  object  moved  downward,  especially  downward  and  out- 
ward, during  which  it  will  be  noticed  that  there  is  limitation  of 
movement  in  this  direction. 

(c)  The  secondary  deviation  of  the  sound  e3'e  is  downward  and  out- 
ward, the  false  projection  of  the  visual  field  is  too  far  downward,  and  the 
face  is  directed  downward  and  to  the  right,  or  the  head  is  tilted  toward 
one  shoulder,  generally  the  right. 


Fig.   254. — A,  Position  of  images  in  paralysis  of  left  superior  oblique,  and  B,  in  paralysis 
of  right  superior  oblique  (after  Fuchs). 

6.  Superior  Oblique. — There  are  present: 

(a)  Vertical  homonymous  diplopia  (sometimes  crossed)  in  the  lower 
field,  the  images  being  one  above  the  other,  the  image  of  the  affected 
eye  being  lower  than  its  fellow,  and  inclined  to  the  left — i.  e.,  to  the 
sound  side — the  vertical  distance  between  them  (difference  in  height) 
widening  as  the  test-object  is  moved  downward  and  to  the  left — that 
is,  there  is  maximum  diplopia  downward  and  to  the  left. 

If  the  test-object  is  moved  downward  and  to  the  right,  and  the 
eyes  are  directed  toward  it,  the  obliquity  of  the  images  increases — i.  e., 
the  false  image  inclines  still  more  toward  the  sound  side.  This  occurs 
because,  in  these  circumstances,  the  vertical  meridian  of  the  left  eye 
is  inclined  toward  the  left  by  the  inferior  rectus,  while  that  of  the 
right  eye  is  not  rotated,  owing  to  the  feeble  superior  oblique;  conse- 
quently, the  meridians  diverge.^ 

1  In  parah'sis  of  the  inferior  rectus  the  diplopia  is  usually  crossed ;  this  feature 
helps  to  distinguish  it  from  paralysis  of  the  superior  oblique.  In  both,  the  image 
of  the  affected  eye  sometimes  seems  to  stand  nearer  to  the  patient  than  the  other 
image.  It  should  be  remembered,  however,  as  Maddox  insists,  that  in  paralysis 
of  any  one  of  the  obliques  a  pre-existing  exophoria  may  compUeate  the  case  to  such 
an  extent  as  to  change  "homonymous"  into  "crossed"  diplopia,  while  in  paraly- 
sis of  the  superior  and  inferior  recti  pre-existing  esophoria  may  convert  "crossed" 
into  "homonymous"  diplopia. 


586    MOVEMENTS   OF   THE   EYEBALLS   AND   THEIR   ANOMALIES 

(6)  The  direction  of  the  affected  eye  is  upward  and  inward,  and  is 
more  noticeable  when  the  eye  attempts  to  follow  an  object  moved 
downward  and  inward,  during  which  it  will  be  noticed  that  there  is 
limitation  of  movement  in  this  direction. 

(c)  The  secondary  deviation  of  the  sound  eye  is  downward  and  in- 
ward, the  false  projection  of  the  visual  field  is  too  far  downward,  and  the 
face  is  inclined  downward  and  to  the  left,  or  the  head  is  tilted  toward  one 
shoulder,  generally  the  left. 

7.  Oculomotor  Paralysis. — There  are  present : 

(a)  Complete  crossed  diplopia,  the  image  of  the  affected  eye  being 
higher  than  its  fellow,  and  its  upper  extremity  incHned  to  the  right — 
i.  e.,  to  the  affected  side — the  distance  between  them — i.  e.,  the  lateral 
distance — widening  as  the  test-object  is  moved  to  the  left.  If  the 
test-object  is  moved  upward  the  difference  in  height  and  the  inclination 
of  the  false  image  increase. 


^^HK^^'                                     ''^m 

■■               M^^M 

^ 

rr: 

r' 

%         **•   ■ 

Ik 

*'  ^SJ^tkk    ' 

Fig.  25.5. — Double  oculomotor  palsy  (from  a  patient  in  Philadelphia  General  Hospital). 


(6)  Divergent  strabismus  and  limitation  of  movement  in  all  directions, 
except  outward  and  slightly  downward. 

(c)  The  secondanj  deviation  of  the  sound  eye  is  outward,  the  false 
projection  of  tlic  field  of  vision  is  to  the  inner  side,  and  the /ace  is  inclined 
toward  the  right,  the  chin  being  tipped  up^rard.  In  addition,  there  are 
ptosis,  medium  dilatation  of  the  pupil  which  fails  to  contract  to  light, 
and  paralysi.s  of  accommodation. 

Method  of  Examination  and  Diagnosis  of  the  Afifected  Eye. — If 
the  i)aralysis  is  complete,  there  is  little  (lilliculty  in  making  a  diagnosis 
by  attention  to  the  prominent  symptoms  wliicli  have  been  detailed. 
If  the  condition  is  one  of  partial  paralysis  (paresis),  the  diagnosis  must 
be  based  upon  an  investigation  of  the  double  images. 

The  patient  is  seated  with  the  head  and  ey(>s  in  the  primary  posi- 
tion, four  meters  from  the  test -object  (a  candle  llame  or  small  electric 
light),  and  a  trial-frame  one  side  of  wiiich  carries  a  red  glass  is  placed 


PARALYSIS    OF    THE    EXTERIOR    OCULAR    MUSCLES  587 

in  position.  Hence  if  diplopia  is  developed,  one  image  will  be  yellow 
and  the  other  red.  The  lighted  candle  is  then  moved  from  the  median 
line  to  the  right,  to  the  left,  upward  and  down,  while  the  patient 
follows  these  movements  with  his  eyes,  the  head  being  stationary. 
By  these  maneuvers  the  following  facts  will  be  ascertained : 

(1)  Double  images  are  chiefly  seen  when  the  eyes  are  turned  in  a 
direction  requiring  an  action  of  the  affected  muscle.  (2)  The  image 
of  the  affected  eye  (false  image)  is  projected  in  a  direction  toward  which 
the  paralyzed  muscle  normally  rotates  the  eye.  (3)  That  image  is  false 
(image  of  the  affected  eye)  which  travels  farther  away  from  the  true 
image  (image  of  the  sound  ej'e)  when  the  test-object  is  moved  in  the 
direction  of  the  paralyzed  muscle — i.  e.,  the  relative  distance  of  the 
double  images  increases  in  these  circumstances. 

The  effect  upon  the  obhquity  of  the  images  and  their  relation  to 
each  other  of  moving  the  test-object  in  obhque  directions  above  and 
below  the  horizontal  plane  must  next  be  studied;  also  whether  the 
images  are  present  in  all  portions  of  the  field  of  fixation,  or  confined  to  a 
certain  area  of  it  (see  also  page  579). 

]\Iany  tables  have  been  prepared  to  aid  in  the  diagnosis  of  the 
affected  muscle,  and  if  paralysis  of  the  oblique  muscles  always  produced 
homonymous  or  simple  diplopia,  and  paralysis  of  the  superior  and  infe- 
rior rectus  muscles  always  caused  heteronymous  or  crossed  diplopia, 
their  construction  would  be  comparative^  simple.  This,  however,  is 
not  the  case,  and  it  is  well  known,  as  has  already  been  pointed  out,  that 
the  diplopia  from  paresis  of  the  obliques  may  be  crossed,  and  that  from 
paresis  of  the  superior  and  inferior  recti  homonymous.  Hence  Duane 
insists  that  paralysis  of  the  obliques  and  of  the  superior  and  inferior 
recti  should  be  diagnosticated  from  the  behavior  of  the  vertical 
diplopia. 

This  author  divides  the  twelve  muscles  moving  the  two  eyes  into 
three  groups  of  four  each:  four  moving  the  ej'es  laterally,  four  moving 
them  up  (elevators),  and  four  moving  them  down.  Each  group  is 
divided  into  two  pairs.  Thus,  the  four  laterally  acting  muscles  are  di- 
vided into  (a)  a  pair  of  right  turners  (right  externus  and  left  internus), 
and  (6)  a  pair  of  left  turners  (right  internus  and  left  externus).  The 
four  elevators  are  divided  into  (a)  a  pair  of  right-hand  elevators  (right 
superior  rectus  and  left  inferior  obhque)  and  (6)  a  pair  of  left-hand 
elevators  (right  inferior  obhque  and  a  left  superior  rectus).  The  four 
depressors  are  divided  into  (a)  a  pair  of  right-hand  depressors  (right 
inferior  rectus  and  left  superior  obhque  and  (h)  a  pair  of  left-hand 
depressors  (right  superior  obhque  and  left  inferior  rectus). 

In  order  to  assist  in  the  diagnosis  of  the  affected  muscle  the  follow- 
ing table  has  been  constructed  by  Dr.  Duane  which  the  author  has 
found  to  be  most  satisfactory,  and  which  Dr.  Duane  permits  him  to 
.  insert : 


588    MOVEMENTS    OF   THE    EYEBALLS    AND    THEIR    ANOMALIES 


TABLE  OF  DIPLOIMA  I.\  OCULAR  MUSCLE  PARALYSIS,  ACCORDING 

TO  DUAXK 

A.  There  is  a  lateral  (i.  e.,  a  honionyinou.s  or  crossed)  diplopia  which  increases 

markedly  as  eyes  are  carried  laterally  (to  rigiit  or  left).     A  laterally  acting 
muscle  is  paralyzed, 
(a)   Diplopia  increa.se.s  in  looking  to  the  ri^ht  (  =  paralysis  of  a  right  turner). 
Diplopia  homonymous:  Paralysis  of  right  e.xternus. 
Dij)lopia  crossed:  Paralysis  of  left  internus. 
(6)   Diplopia  increases  in  looking  to  the  left  ( =  paralysis  of  a  left  turner). 
Diplopia  cros.sed:  Paralysis  of  right  internus. 
Diplopia  homonymous:   Paralysis  of  left  e.xternus. 

B.  There  is  vertical  diplopia  which  increases  in  looking  up.     An  elevator  is  par- 

alyzed. 

(a)  Vertical  diplopia  increa.ses  in  looking  up  and  to  the  right  (  =  paralysis  of  a 

right-handed  elevator). 
Diplopia  left  (i.  e.,  image  of  right  eye  above):  Paralysis  of  right  superior 

rectus. 
Diplopia  right  (z.  e.,  image  of  left  eye  above):  Paralysis  of  left  inferior 

oblique. 

(b)  Vertical  diplopia  increases  in  looking  up  and  to  the  left  ( =  paralysis  of  a 

left-hand  elevator). 
Diplopia  left  (i.  e.,  image  of  right  e\e  above):  Paralysis  of  right  inferior 

oblique. 
Diplopia  right  (i.  e.,  image  of  left  eye  above):  Paralysis  of  left  superior 

rectus. 

C.  There  is  a  vertical  dijjlopia  which  increa.ses  in  looking  down.     A  dcpres.sor  is 

paralyzed. 

(a)  Vertical  diplopia  increa.ses  in  looking  down  and  to  the  right  ( =  paralysis 

of  a  right-hand  depressor). 
Dijilopia  right  (t.  e.,  image  of  right  eye  below):  Paralysis  of  right  inferior 

rectus. 
Diplopia  left  (i.  e.,  image  of  left  eye  below):  Paralysis  of  left  superior 

oblique. 

(b)  Vertical  diplopia  increases  in  looking  down  and  to  the  left  (  =  paralysis  of 

a  left-hand  depressor). 
Dil)loj)ia  right  {i.  e.,  image  of  light  eye  below):  Paralysis  of  right  su{)erior 

oblicjue. 
Dijjlopia  left  (i.  e.,  image  of  left  eye  below):  Paralysis  of  left  inferior  rectus. 
To  illustrate  the  practical  working  of  the  table  the  following  example  is  (pioted: 
The  j)atieiit  with  a  red  glass  before  tlu^  right  eye  is  directed  to  observe  a  candle 
which  is  moved  in  all  directions  in  his  field  of  fixation.  If  the  patient  has  single 
vision  when  he  looks  down,  but  has  vertical  diplopia  when  he  looks  up,  paralysis 
of  an  elevator  is  inferred.  The  vertical  diplopia  increa.ses  greatly  when  he  looks 
uj)  and  to  the  right,  and  diminishes  to  almost  nothing  when  he  looks  up  ami  to  the 
left.  The  paralysis  must  affect  a  right-hand  elevator  (right  su|)erii)r  rectus  or 
left  inferior  obliciue).  The  red  image  is  higher  (left  diplopiji  =  right  eye  l)elow). 
The  paralysis  must  alTect  the  right  superior  r(>ctus.  If  it  had  been  tlie  left  inferior 
ol)li(|ue,  the  red  image  would  have  been  the  lower;  and  if  it  had  l)een  either  the 
right  inferior  obli(|ue  or  the  h^ft  superior  rectus,  the  vertical  diplopia  would  have 
increased  not  when  the  patient  looked  up  and  to  the  right,  but  when  he  looked  up 
and  (()  the  left. 

Causes.  Tlic  lcsi(tti  which  cjuiscs  paralysis  of  an  ocular  nniscie 
iWAV  h;i\('  ail  liitnicrduidl,  urhHtd,  or  peri jtlmal  situation.  If  iutra- 
ciaiiial,  it  may  he  ccrihral  tli.at  is,  cortivtd.  iiuclcur,  or  /(iscicuhir  in 
situation,  or  else  basal. 


PARALYSIS    OF    THE   EXTERIOR   OCULAR   MUSCLES  589 

Among  the  conditions  residing  in  the  orbit  which  produce  paralysis 
of  the  exterior  ocular  muscles,  the  so-called  orbital  palsies,  are  cellulitis, 
tenonitis,  periostitis,  tumors,  metastatic  carcinomatous  nodules  (Elsch- 
nig),  hemorrhage,  fracture,  and  affections  of  the  sinuses. 

Syphilis  causes  about  one-half  of  the  cases  of  exterior  ocular  muscle 
palsies — according  to  Alexander,  59.4  percent.^  The  resulting  paral- 
ysis may  be  due  to  an  inflammation  or  gummatous  change  affecting  the 
nerves  at  the  base  of  the  brain  or  in  the  orbit,  or  it  may  be  central  in 
origin  from  disease  of  the  nuclei  of  the  nerves  or  of  the  brain  in  their 
immediate  vicinity,  or  from  lesions  in  the  third  ventricle,  the  aqueduct 
of  S\dvius,  or  the  fourth  ventricle.  Sj'philitic  paralysis  is  generally 
one  of  the  later  manifestations,  but  it  has  been  noted  as  early  as,  or 
even  earlier  than,  the  sixth  month  after  the  primary  infection,  particu- 
larh'  in  the  form  of  ptosis.  Syphilis  attacks  the  oculomotor  most 
frequently,  next  in  order  the  abducens  and  least  frequently  the  troch- 
learis,  isolated  palsy  of  which  is  very  rare.  Paralj'sis  of  the  ocular 
muscles  from  inherited  sj^philis  is  comparatively  unusual,  something 
over  thirty  eases  being  recorded  in  the  literature  (Igersheimer). 

Other  causes,  some  of  which  at  times  occasion  central — that  is,  nu- 
clear— lesions,  and  at  other  times  act  peripherally,  are  rheumatism, 
gout,  diabetes,  whooping-cough,  influenza,  herpes  zoster,  and  certain 
toxic  agents — for  example,  lead,  alcohol,  tobacco,  gelsemium,  conium, 
chloral,  carbonic  acid,  and  fish-,  sausage-,  sour  cheese-  and  meat-poison- 
ing (ptomain-poisoning,  toxalbumins,  botulism,  and  allantiasis).  The 
ocular  manifestations  of  botulism  may  come  on  early,  but  usually  do 
not  appear  for  several  days.  Paresis  of  accommodation  and  ptosis  are 
common,  but  other  branches  of  third  nerve  are  also  involved;  also  the 
sixth  and  fourth.  The  lesions  are  probably  usually  nuclear.  While 
the  prognosis  is  generally  good,  fatal  outbreaks  of  botulism  caused 
by  eating  contaminated  olives  have  occurred;  the  toxin  depended  on 
tj'pe  A  of  the  bacillus  botulinus. 

The  external  rectus  is  the  muscle  most  affected  by  rheumatism  and 
diabetes  and  often  by  influenza,  but  the  palsy  may  also  be  syphilitic 
in  origin  (13  per  cent,  ([Igersheimer]).  So-called  rheumatic  palsies, 
as  Mauthner  has  pointed  out,  may  be  followed  3'ears  after  bj-  tabes  of 
the  cord,  disseminated  sclerosis,  or  paratytic  dementia.  Although  diph- 
theria usually  affects  the  ciliary  muscle,  it  may  attack  one  or  more  of 
the  exterior  muscles,  generally  the  external  rectus.  The  condition  may 
be  bilateral.  Rarely  complete  ophthalmoplegia  occurs.  Otitis  media, 
with  isolated  parah'sis  of  the  abducens  on  the  corresponding  side  and 
intense  unilateral  headache  is  know^n  as  Gradenigo^s  symptom-complex, 
and  usually  requires  operation  from  the  otologic  standpoint  for  its 
relief.  Abducens  pais}'  with  paresis  of  accommodation  has  been  re- 
ported as  the  result  of  dengue  fever  (Barkan)  and  has  followed  nasal 

'  The  frequency  of  syphilis  as  a  cause  of  ocular  muscle  palsy  has  been  variously 
estimated  from  18  to  60  per  cent.  Modern  methods  of  determining  the  etiologic 
factor  in  ocular  muscle  palsies,  that  is  the  Wassermann  test,  etc.,  will  improve 
the  accuracy  of  later  statistical  information. 


590    MOVEMENTS   OF   THE    EYEBALLS   AND   THEIR   ANOMALIES 

trauma  and  infection  (Ewing.  Sluder).  The  author  has  seen  one  case 
of  complote  isolated  pais}'  of  the  internal  rectus  which  took  place 
immediately  after  the  removal  of  a  nasal  polyp. 

The  diseases  and  lesions  which  attack  the  nerves  at  the  base  of  the 
brain,  and  thus  occasion  the  so-called  basal  palsies,  are  hemorrhage, 
meningitis,  both  simple  and  tubercular,  particularly  the  latter,  abscess, 
for  example,  in  connection  with  middle-ear  disease,  sinus  disease, 
aneurysm,  diseases  of  the  cavernous  sinus,  pituitarj^  body  disease, 
syphilis,  and  tumors.  Spinal  anesthesia  may  be  followed  by  palsy  of 
the  exterior  ocular  muscles,  the  external  rectus  being  most  fre- 
quently involved.  It  probably  depends  upon  a  toxic  reaction  in  the 
meninges. 

A  number  of  paralyses  of  the  exterior  ocular  muscles  are  seen  in 
connection  with  locomotor  ataxia,  paretic  dementia,  disseminated 
sclerosis,  and  bulbar  paralysis.  Tabetic  paralysis  is  often  transitory  in 
its  nature;  it  may  be  associated  with  the  pupillary  changes  character- 
istic of  this  affection.  Relapses  are  frequent.  Sherrington  has  dem- 
onstrated that  the  third,  fourth,  and  sixth  nerves  contain  afferent 
fibers  which  are  not  derived  from  the  fifth  nerve,  and  concludes  that 
tabetic  ocular  palsies  are  probabl}'  due  to  implication  of  these  afferent 
fibers  and  not  to  the  implication  of  the  efferent  fibers  of  the  ocular 
nerves.  Paral3'ses  of  the  orbital  muscles  of  cerebral  origin  may  result 
from  degenerative,  hemorrhagic,  or  neoplastic  lesions  affecting  the 
cortex  of  the  brain,  the  corticopeduncular  region,  the  nuclei  of  the 
nerves,  or  the  nuclear  fibers.  Lethargic  encephalitis,  a  disease  very  pre- 
valent in  recent  years,  has  conspicuously  among  its  manifestations  par- 
esis and  paralysis  both  of  the  exterior  and  interior  ocular  muscles.  In 
mild  type  the  muscle  palsies  subside  with  the  disappearance  of  the  other 
symj)toms.  In  severe  cases  there  may  be  complete  ophthalmoplegia; 
in  other  cases  individual  muscles  may  be  affected.  The  palsy  of  the 
ciliar}'  muscle  may  be  long  continued.     Nystagmus  is  not  infrequent. 

Injuries  may  cause  ocular  muscle  palsy — for  example,  the  muscle 
may  be  torn  or  the  nerve-trunk  divided,  or  there  may  be  paralysis 
owing  to  periostitis  of  the  orbit,  fracture  of  the  orbital  walls  or  base 
of  the  skull.  The  palsy  may  develop  secondarily  from  basal  ini>niiigi- 
tis,  abscess,  or  nuclear  degeneration. 

Anomalies  of  the  exterior  muscles  may  occur,  depending  upon  tluMr 
abnormal  insertion.  Entire  al)sence  of  a  muscle  lias  been  noteil.  Oc- 
casionall}^  cases  of  orbital  muscle  palsy  have  been  attributed  to  va- 
rious so-called  reflex  (linturbance.s. 

Recurrent  Oculomotor  Paralysis  {Ophthahnoplegic  Migraine — 
Charcot). — The  syinploms  of  tiiis  coiiiparativc^ly  rare  affection  are 
violent  uiiilaieral  headache,  nausea,  vomiliiig,  slight  fever,  ami  usually 
paralysis  of  (he  third  nerve  on  the  same  side  as  the  pain.  The  attacks 
come  in  periodic  crises,  and  the  disease  may  last  from  several  days  to 
long  periods  of  time.  Occasionally  the  paralysis  remains  permanent. 
The  lesion  is  probabl.N'  one  involving  th(>  root  of  th(>  thir»l  nerve.  Re- 
current  paralysis  of  the  alxhicens  has  been  ol)serve(l. 


REACTION  MOVEMENT  OF  THE  EYEBALL        591 

Congenital  Paralysis  {Congenital  Deviation — Duane). — Congeni- 
tal palsies  of  the  exterior  ocular  muscles,  usually  stated  to  be  uncom- 
mon, are  comparatively  frequent  if  slight  deviations  are  taken  into 
account.  They  have  been  particularly  well  studied  by  Duane. ^  Ac- 
cording to  him,  insufficiency  of  the  superior  rectus,  with  fixation  with 
the  paretic  eye  and  secondary  deviation  (upshoot)  of  the  other  eye,  is 
not  infrequent.  A  striking  feature  is  that  when  the  fixing  eye  moves 
outward,  the  other  shoots  spasmodically  up  and  in  (spasmodic  action 
of  the  inferior  oblique) .  Other  groups  described  by  Duane  are  palsy  of 
the  superior  rectus  with  fixation  with  the  non-paretic  eye;  slight  and 
marked  insufficiency  of  the  inferior  rectus;  insufficiency  of  the  inferior 
and  superior  oblique  and  combined  insufficiencies  of  the  vertical  and 
lateral  muscles.  Congenital  palsy  of  one  or  both  externi  is  not  un- 
common, and  may  be  associated  with  retraction  movements  (see  next 
paragraph).  The  symptoms  of  congenital  palsy  usually  are:  head- 
tilting,  diplopia,  vertigo,  and  asthenopia.  The  patients  nearly  always 
close  the  defective  eye. 

Retraction  Movement  of  the  Eyeball,  Associated  with  Con= 
genital  Deficiency  of  Abduction. — Certain  cases  of  congenital  defi- 
ciency of  movement  of  the  eyeball  are  characterized  by  all  or  some  of 
the  following  symptoms,  which  have  been  thus  summarized  by  Duane : 
Usually  complete,  occasionally  partial,  absence  of  outward  movement 
of  the  affected  eye;  partial  defect  of  inward  movement  of  the  affected 
eye;  retraction  of  the  affected  eye  into  the  orbit  when  it  is  adducted;  a 
sharp,  obHque  movement  of  the  affected  eye  up  and  in  or  down  and  in 
when  it  is  adducted;  partial  closure  of  the  eyelids  of  the  affected  eye 
when  it  is  adducted;  and  paresis  or,  at  least,  marked  deficiency  of  con- 
vergence, the  affected  eye  remaining  fixed  in  the  primary  position, 
while  the  sound  eye  is  converging.  Enophthalmos  may  be  present  in 
primary  position  of  the  eyelids  (A.  Lutz). 

The  affection  is  undoubtedly  congenital.  Females  are  more  usu- 
ally affected  than  males.  The  affection  has  been  explained  by  assum- 
ing that  the  externus  is  replaced  by  an  elastic  or  inelastic  strand  of 
connective  tissue,  or  that  a  faulty  insertion  of  the  internus  causes  it  to 
act  as  a  retractor.  The  oblique  upward  and  downward  movements  of 
the  eye  observed  in  many  of  these  cases  during  adduction  are  attributed 
by  Duane  to  a  spasmodic  action  of  one  of  the  obliques.  Operative  pro- 
cedures have  been  suggested  for  cosmetic  purposes — namely,  tenotomy 
of  the  retracted  muscle  and  fixation  of  the  globe  in  the  opposite  posi- 
tion (Wolff). 

It  is  often  difficult  to  ascertain  whether  the  paralysis  is  central  or 
peripheral  in  its  origin.  The  differential  diagnosis  must  be  made  by 
examining  into  the  completeness  of  the  paralysis  and  the  existence  of 
complications  or  associated  symptoms.  Peripheral  palsies  are  more 
apt  to  be  isolated  and  complete;  those  of  central  origin  are  often  asso- 
ciated with  other  symptoms  indicative  of  intracranial  mischief. 

1  Transactions  of  the  American  Ophthalmological  Society,  Vol.  xii,  Part  iii, 
1911. 


592  MOVEMENIS  OF  THE  EYEBALLS  AND  THEIR  ANOMALIES 

Relative  Frequency  of  Paralysis  of  the  Orbital  Muscles. — Paralysis 
of  the  alxluccus  (external  rectus)  is  met  with  most  freciuentiy.  the  next 
in  order  of  fre(iuencj^  being  unilateral  paralysis  of  the  oculomotor. 
After  these  come  paralysis  of  the  superior  oblique,  inferior  rectus, 
superior  rectus,  internal  rectus,  and  inferior  oblique.  However,  statis- 
ticians differ  exceedingly  on  these  points — c.  {/..  Duane  ranks  the  supe- 
rior rectus  next  to  the  external  rectus. 

The  prognosis  depends  upon  the  cause  of  the  palsy.  Some  cases 
of  peripheral  paralysis,  especially  those  depending  upon  syphilis  and 
rheumatism,  are  readily  amenable  to  treatment;  in  others  not  only  is 
the  paralysis  incurable,  but  the  lesion  which  creates  it  may  l)e  a  fatal 
one.  Hence  the  importance  of  trying  to  ascertain  the  character  ami 
situation  of  the  lesion  which  produces  the  palsy. 

Treatment. — In  syphilis  the  usual  remedies  are  applicable,  aiul  in 
manj'  instances  good  results  follow  very  large  doses  of  iodid  of  potas- 
sium. Massive  doses  are  often  tolerated,  and  even  if  the  paralysis  has 
existed  for  a  long  time,  cure  may  ultimately  result.  Salvarsan,  in  the 
author's  experience,  is  of  comparatively  little  service  in  luetic  palsy  of 
the  exterior  ocular  muscles,  that  is,  in  cases  of  long  standing.  In 
those  cases  of  ocular  muscle  palsy  which  develop,  often  the  external 
rectus,  in  patients  who  are  the  suV)ject  of  various  forms  of  chronic 
rheumatism  and  myalgia,  in  addition  to  iodid  of  potassium,  salicylic 
acid  is  u.seful,  especially  in  the  earlier  stages.  Disturbances  of  meta- 
bolism, as  for  example,  gout  and  diabetes  require  the  usual  treatment. 
The  various  causes  which  have  V)een  mentioned  furnish  the  indica- 
tions for  other  treatment.  Care  should  always  \)v  taken  to  examine 
the  nasal  accessory  sinuses  for  sources  of  infection  and  the  intestines 
for  the  evidences  of  toxic  products. 

The  great  annoyance  wiiicli  is  produced  by  the  doul)le  images  may 
l)e  remedied  Ijy  covering  the  affected  eye  witli  a  piece  of  ground  glass, 
which  is  mounted  in  a  spectacle-frame.  If  the  patient  is  ametropic, 
his  correcting  lens  for  the  opposite  eye  may  be  placed  in  the  same 
frame. 

Sometimes  prisms  may  be  worn  whicii  fuse  t  he  doulile  images.  Tlie 
rules  for  adjusting  pi'isms  are  given  on  page  (lb"). 

Mechaniail  trcatniwi  was  suggested  by  Michel,  and  was  triiul  in  this 
country  by  liull.  The  conjunctiva  is  seized  near  the  insertion  of  the 
affected  muscle  with  forceps,  and  the  eyeball  is  drawn  forcil)ly.  as  far 
as  possi})le,  beyond  the  oidinary  limit  of  contraction,  and  then  back 
again.  The  e\('  is  first  cocainized.  The  movements  are  made  daily, 
and  continued  for  a  minute  at  a  time.  This  recomm(Muhition  in  the 
author's  experience  is  without  wihic 

lOlect  r-icity  nia>'  l>e  fiicd,  the  gical  (hiiiculty  Ix'ing  in  passing  the 
current  through  the  muscle.  ( )i(niiaiily,  one  pole-  the  cathode  is 
I)hic<'(|  upon  the  cldscd  lid.  while  llie  oilier  is  put  upttn  the  leiujile. 
L  suall>  ,  a  current  of  more  than  W  milliauipeics  is  unbearalile.  This  i.s 
especially  true  if  iIk  pole  is  |)laced  directly  U|)on  the  seleia,  the  «'ye 
first    having  been  eocaini/.ed.      \'eiy  disagreeal>le  llaslies   of    light    will 


OPTHALMOPLEGIA  593 

usually  take  place  if  a  current  of  more  than  1  or  1}^  milliamperes  is  em- 
ployed. If  faradism  is  tried,  a  very  weak  current  should  be  selected. 
Finally,  after  all  other  means  have  failed,  tenotomy  of  the  con- 
tracted muscle  has  been  resorted  to,  but  usuall}-  is  successful  onlj'  if  it  is 
combined  with  advancement  of  the  paralyzed  muscle.  The  best 
results  are  obtained  in  the  lateral  muscles.  In  case  an  injured  muscle — 
that  is,  one  torn  from  its  insertion — should  it  be  seen  soon  after  the  acci- 
dent, it  would  be  proper  to  find  the  ends  of  the  divided  muscle  and 
stitch  them  together.  Indeed,  advancement  of  a  severed  muscle  is 
quite  possible  long  after  the  accident  or  after  a  too  extensive  tenotomy. 
Operation  for  paralysis  of  the  superior  oblique  to  neutralize  the  diplopia 
would  require  tenotomy  of  the  inferior  rectus  of  the  opposite  eye,  or 
advancement  of  the  inferior  rectus  of  the  paralyzed  eye  (Landolt). 
The  former  procedure  is  preferable.  So,  too,  paralysis  of  an  inferior 
oblique  would  require,  to  relieve  diplopia,  tenotomy  of  the  superior 
rectus  of  the  opposite  e^-e  (see  also  page  608). 

Ophthalmoplegia. — Although  the  term  "ophthalmoplegia" 
might  with  perfect  propriety  be  used  to  describe  all  the  ocular  muscle 
palsies,  it  is  generalh'  reserved  for  that  class  of  parah'ses  of  the  orbital 
muscles  due  to  disease  of  the  nuclei  of  the  third,  fourth,  and  sixth 
nerves.  In  certain  clinical  cases  it  is  not  possible  to  determine  whether 
the  lesion  is  nuclear  or  in  the  nerves.  Ophthalmoplegia  may  be 
divided  into  acute  ophthalmoplegia  or  acute  nuclear  palsy,  and  into 
chronic  ophthalmoplegia  or  chronic  nuclear  palsy.  "When  it  so  happens 
that  the  intra-ocular  muscles  alone  are  affected,  the  term  interior 
ophthalmoplegia  is  sometimes  employed,  and  when  the  exterior  muscles 
alone  are  affected,  the  term  exterior  ophthalmoplegia.  When  both  sets 
of  muscles  are  involved,  the  term  total  ophthalmoplegia  is  appropriate. 
Acute  ophthalmoplegia  is  characterized  bj'  a  rapid  paralysis  of  all 
ocular  muscles,  often  associated  with  fever  and  convulsions.  Many 
of  the  cases  have  proved  to  be  fatal.  They  occur  with  hemorrhage  in 
the  region  of  the  nuclei,  or  as  an  acute  hemorrhagic  polio-encephalitis, 
the  primary  cause  being  tuberculosis,  syphilis,  ptomain-toxemia 
(botulism),  or  poisoning  from  alcohol  or  sulphuric  acid.  Acute  oph- 
thalmoplegia may  be  associated  with  acute  poliomyelitis,  with  bulbar 
palsy,  or  with  facial  palsy.  According  to  Oppenheim,  an  acute  oph- 
thalmoplegia maj"  be  the  result  of  a  peripheral  neuritis  of  nerves  of  the 
ocular  muscles.  Certain  poisons — for  example,  nicotin,  lead,  and  car- 
bon monoxid — may  cause  an  ophthalmoplegia  which  is  not  fatal,  or,  at 
least,  not  necessarily  fatal,  and  the  same  is  true  of  one  type  which  is 
seen  with  certain  constitutional  and  infectious  diseases — for  instance, 
diabetes,  syphilis,  lethargic  encephalitis,  and  influenza.  Transient 
bilateral  ophihalmoplegia  has  been  described,  the  symptoms  developing 
rapidly  and  disappearing  completely  after  one  or  two  months. 

Chronic  ophthalmoplegia  is  characterized  by  loss  of  power  in  one  or 
more  eye  muscles,  which  may  gradually  increase  until  every  muscle  is 
paralyzed.  Sometimes  the  levator  escapes;  indeed,  ptosis  may  be 
absent.     The  disease  may  be  stationary  or  progressive.     It  is  not  always 

38 


594    MOVEMENTS   OF    THE    EYEBALLS    AND   THEIR   ANOMALIES 

symmetric;  it  may  be  unilateral.  Chronic  ophthalmoplegia  may 
follow  an  acute  palsy,  the  lesions  of  which  have  started  chronic  de- 
generative changes;  it  may  appear  as  a  congenital  and  occasionally 
hereditary  affection,  usually  in  the  form  of  bilateral  ptosis.  Thus. 
A.  A.  Bradburne  observed  ptosis,  with  almost  complete  loss  of  ocular 
movement,  in  a  family  where  this  affection  had  been  present  in  five 
generations.  Sometimes  epicanthus  complicates  the  ptosis.  Oph- 
thalmoplegia is  seen  in  association  with  locomotor  ataxia,  paretic 
dementia,  progressive  muscular  atrophy,  chronic  bulbar  paralysis, 
and  disseminated  sclerosis.  The  underlying  constitutional  condition 
may  be  syphilis  and  sometimes  tuberculosis.  The  disease  is  essentially 
chronic,  and  may  last  for  years.  It  is  more  common  in  males  than  in 
females,  and  is  more  serious  in  children  than  in  adults. 

The  intra-ocular  muscles  usually  escape,  but  this  is  not  always  the 
case.  If  they  escape  there  is  presumptive  evidence  that  the  origin  of 
the  trouble  is  nuclear,  but,  as  Mauthner  pointed  out,  it  is  not  a 
characteristic  sign,  and  a  partial  palsy  may  be  peripheral.  Siemerling 
concludes  that  nuclear  disease  may  be  inferred  from  exterior  ophthalmo- 
plegia, if  it  is  not  maintained  that  nuclear  palsy  must  manifest  itself 
as  an  exterior  ophthalmoplegia.  In  general  terms  the  lesions  are 
degenerative,  inflammatory,  or  hemorrhagic.  According  to  SiemerUng, 
the  pathologic  states  underlying  progressive  paralysis  of  the  ocular 
nuiscles  may  reside  in  nuclear  disease,  in  degeneration  of  the  nuiscles 
and  of  the  nerve-trunks,  the  nuclei  being  intact,  and  in  interruption  of 
the  conducting  power  of  the  intramedullary  roots,  nmscles,  nerve- 
trunks,  and  nuclei  being  uninvolved. 

Treatment. — In  many  instances  this  is  wholly  witliout  result. 
If  syphilis  is  present,  the  usual  remedies  are  applicable,  esi)ecially  iodid 
of  potassium  in  massive  doses. 

Associated  Ocular  Paralyses  (Conjugate  Deviation). — Sometimes 
the  eyes  cannot  make  certain  movements  in  which  they  are  usually 
associated,  although  the  tlirecting  i)0wer  of  the  nuiscles  may  be  unim- 
paired when  they  exercise  their  function  in  a  different  association. 
In  other  words,  there  is  paralysis  of  movement  and  not  of  the  muscles 
supplied  Ijy  a  given  nerve  (paralysis  of  ocular  gyration).  Thus  the 
internal  recti  may  Ije  unable  to  draw  the  eyes  together  in  the  act  of 
convergence,  although  they  may  act  normally  in  helping  to  move  the 
eyes  from  side  to  side;  or  there  may  be  loss  of  the  synchronous  lateral 
movement  of  the  external  rectus  of  one  eye  and  the  internal  rectus  of 
the  other  (conjugate  lateral  paralysis),  although  convergence  is  nornud; 
or  the  upward  or  downward  movements  of  the  eye  nia>' be  lost.  Le- 
sions affecting  the  centers  for  combined  niovi'inents  may  produce  such 
phenomena,  the  majority  of  these  palsies  being  due  to  a  lesion  involving 
the  abducens  muscles.  Acconling  to  Spiller,  i)aralysis  of  lateral  asso- 
<'iale(l  movement  may  b(»  caused  by  a  lesion  of  the  posterior  longitudi- 
nal l)un(lle  or  of  the  sixth  imcleus;  synnnelrii'  disease  of  the  mulei  of 
the  alfeclcd  neive  explains  some  cases  in  which  the  upward  and  the 
ilowiiw.ird  movemeiil  are  lost.      The  lesion  nuiy  be  in  or  near  t  he  corpor.'i 


PARALYSIS    OF    THE    INTERIOR    OCULAR    MUSCLES  595 

quadrigemina.  Holmes  and  Sargent  have  described  disturbance  of 
ocular  movement  with  injury  of  the  superior  longitudinal  sinus;  in  one 
group  temporary  palsy  of  associated  conjugate  movements  occurred, 
attributed  to  implication  of  the  posterior  part  of  each  frontal  convolu- 
tion. Typical  spasmodic  conjugate  deviation  may  be  caused  by 
hysteria,  and  this  neurosis  may  also  originate  palsy  of  associated 
parallel  movements. 

In  apoplexy,  if  the  head  is  drawn  from  the  paralyzed  side  and  the 
eyes  are  also  turned  to  the  sound  side,  the  condition  is  called  conjugate 
deviation  of  the  head  and  eyes.  The  rule  is,  according  to  Prevost,  that 
in  lesions  of  the  hemisphere  the  eyes  are  turned  toward  the  lesion  and 
away  from  the  paralyzed  side,  but  in  lesions  of  the  mesencephalon  they 
are  turned  away  from  the  lesion  and  toward  the  paralyzed  side.  Should 
there  be  unilateral  convulsions,  with  the  eye  turned  toward  the  con- 
vulsed side,  there  is  an  irritative  lesion  in  the  hemisphere,  but  if  the 
head  and  eyes  are  turned  away  from  the  convulsed  side,  there  is  an 
irritative  lesion  in  the  mesencephalon  (Landouzy). 

Divergence  Paralysis. — This  condition  which  is  usually  sudden 
in  onset  manifests  itself  by  homonymous  diplopia  and  convergent 
strabismus  when  the  eyes  are  fixed  upon  a  distant  point,  i^.s  the  test- 
object  approaches  the  patient,  and  especially  on  lateral  fixation,  there  is 
diminution  of  the  convergent  strabismus  and  the  diplopia,  and  finally 
a  point  maj^  be  reached  where  there  are  single  vision  and  orthophoria, 
while  within  this  limit  there  may  be  exophoria.  Cases  of  this  char- 
acter have  been  described  as  secondary  to  an  abducens  paralysis,  and 
also  ascribed  to  spasm  of  convergence  and  to  paralysis  of  a  supposed 
divergence  center.  Berry  believes  the  correct  diagnosis  of  this  condi- 
tion to  be  spasm  of  convergence  and  not  paresis  of  divergence.  Duane, 
however,  maintains  that  the  only  satisfactory  explanation  of  the 
phenomenon  is  that  it  is  due  to  a  paralysis  of  divergence.  It  occurs  at 
all  ages,  and  more  often  in  conjunction  with  hyperopia  than  myopia. 
He  suggests  that  a  lesion  near  the  two  abducens  nuclei  would  cause 
this  condition.  As  causes  Alger  records  cerebral  hemorrhage,  nephritis 
with  high  tension,  tabes  dorsalis  and  multiple  sclerosis. 

Convergence  Paralysis. — This,  as  an  extreme  variety  of  conver- 
gence insufficiency,  referred  to  on  page  610.  The  symptoms  are: 
crossed  diplopia,  divergent  strabismus,  which  increases  as  the  test- 
object  is  made  to  approach  the  eye,  no  increase  of  diplopia  either  to 
the  right  or  left,  and  normal  rotation  of  each  eye  outward  and  inward. 
It  has  been  observed  in  various  central  nervous  disorders,  and  notably 
in  locomotor  ataxia  and  disseminated  sclerosis. 

Paralysis  of  the  Interior  Ocular  Muscles. — Under  the  general 
term  cycloplegia  are  included  the  cases  of  paralysis  of  the  ciliary  muscle. 
These  may  or  may  not  be  associated  with  dilatation  of  the  pupil. 

If  the  ciliary  muscle  is  paralyzed,  the  chief  symptom  is  loss  of 
accommodation,  precisely  as  it  occurs  after  the  instillation  of  a  myd- 
riatic. The  loss  of  accommodation  may  be  complete  or  it  may  be 
partial;  that  is,  one  or  more  diopters  of  the  entire  amount  which  is 


596    MOVEMENTS    OF   THE    EYEBALLS    AND   THEIR    ANOMALIES 

normal  at  the  patient's  time  of  life  may  .^till  remain.     After  the  fiftieth 
year  it  is  difficult  to  detect  cydoplepia. 

It  occurs  from  a  lesion  in  the  trunk  of  the  oculomotor  nerve  or  in 
the  anterior  part  of  its  nucleus  (consult  also  oculomotor  palsy  and 
ophthalmoplegia).  Unilateral  cj'doplegia  is  said  to  be  possible  under 
the  influence  of  disease  of  the  ciliary  ganglion.  Paralysis  of  accom- 
modation may  be  caused  by  affections  of  the  nervous  system,  infectious 
diseases,  and  bj'  intoxications.  A  very  common  cause  of  double 
paralysis  of  the  ciliar}'  muscle  is  diphtheria.  Cydoplegia  is  also  oc- 
casioned by  spinal  disease,  by  diabetes,  by  disease  of  the  accessory 
sinuses,  by  various  focal  infections,  by  so-called  auto-intoxication,  by 
disorders  of  metabolism,  by  traumatism  (usually  then  associated 
with  mj'driasis),  by  prolonged  eye-work,  l)y  mumps,  by  tonsillitis,  anil 
frequently  by  acquired  syphilis,  and  is  often  associated  with  paralysis 
of  the  sphincter  of  the  iris.  Inherited  syphilis  is  a  rare  cause  of  paral- 
ysis of  accommodation.  Paresis  of  the  ciliary  muscle  is  common  after 
certain  fevers — for  example,  typhoid  fever.  Various  ptomains.  toxins, 
fish,  and  meat  poisonings  may  cause  both  paresis  and  paralysis  of  the 
ciliary  muscle.  Congenital  interior  ophthalmoplegia  is  a  rare  anomaly 
(Duane).  Toxic  and  traumatic  cycloplegias  are  usually  peripheral; 
syphilitic  and  parasyphilitic  varieties  may  be  peripheral,  liasal.  and 
nuclear  in  origin. 

Under  the  general  term  iridoplajia  are  inckuletl  the  conditions 
which  occur  when  there  is  loss  either  of  the  direct  or  of  the  associated 
action  of  the  iris,  due  to  paralysis  of  its  sphincter.  The  chief  symptom 
is  connected  with  changes  in  the  action  of  the  pupil.  The  comlition 
maj^  or  may  not  be  accompanied  with  paralysis  of  the  ciliary  nnisde. 
The  various  pupillary  changes  have  been  discussed  in  Chapter  II. 
page  55.     Consult  also  page  594. 

Concomitant  StrabismiisorSquint  :Heterotropia. — Thisform 
of  sti'al)isinus  is  duiractcrized  l)y  liie  powei-  ol'the  S(juint  injicye  to  follow 
the  movements  of  the  other  eye  in  all  directions,  the  angle  of  sciuint 
always  maintaining  the  same  size. 

Varieties  of  Concomitant  {Comitant)  Strabismus.  -The  chief  de- 
viations of  s(iuintiiig  eyes,  as  already  given,  are:  coitrtriunt  strahistnuisov 
esotropia;  diveryou  .strahisinus,  or  cxotropia;  and  rertical  slnd)istnHs,  or 
hypertropia.  Concomitant  squint  maj'  be  periotlic  or  constant.  The 
latter  variety  is  divided  into  monocular  squint,  that  is,  in  orilinary  cir- 
cvHTistances  the  same  eye  always  deviates  when  the  other  eye  is  used 
for  fixation,  and  alternatimj  squint,  that  is,  either  eye  is  used  indif- 
ferently for  fixation,  l^ateral  s(iuint  is  usually  associated  with  up- 
ward deviation.  It  is  pr()bal)le  tiiat  at  first  squint  is  generally  periodic, 
but  with  repeated  reciu'rences,  as  Priestley  Smith  expresses  it,  the 
supi)i('Ssion  of  the  deviating  image  becomes  confirmed,  and  tlu>  s(iuinl 
becomes  continuous.  The  ordei'  of  events  according  to  Duane  is  at? 
follows:  a  child  with  a  decided  degree  of  hyjjeropia  or  astigmatism, 
when  he  begins  to  use  his  eyes  for  dose  observation  develops  a  spas- 
modic csopliaria  (convcrgcnrc-spasvi) ;  later  l)inocular  vision  In-ing  iinpos- 


*  i 


CONCOAIITAXT    STR.\BISMUS    OR    SQUINT:    HETEROTROPIA    597 

sible,  periodic  squint  appears  (diplopia  may  be  detected) ;  still  later 
binocular  fixation  is  lost  and  the  squint  becomes  continuous;  still 
later  divergence  insufficiency  is  added  and  finally  muscular  changes 
arise,  that  is  rotation  inward  is  excessive,  rotation  outward  reduced. 
The  average  age  for  convergent  squint  to  begin  is  three  and  four-tenth 
years,  although  it  is  often  noticeable  during  the  first  year  of  life. 
Squints  occurring  after  five  years  are  apt  to  be  alternating,  in  which 
case  excellent  vision  exists  in  each  eye.  According  to  Duane,  a  slight 
vertical  congenital  deviation  may  be  the  starting-point  of  a  progres- 
sive lateral  deviation,  which  is  unnoted  until  the  child  is  five  or  six 
years  of  age. 

Causes  of  Concomitant  (Comitant)  Strabismus. — The  etiology  of 
strabismus  has  occasioned  much  discussion,  and  even  at  this  time  is 
not  a  settled  question.  In  general  terms,  the  factors  which  have  been 
considered  important  in  the  causation  of  squints  may  be  summarized 
as  follows : 

1.  Disturbance  of  the  relation  between  accommodation  and  con- 
vergence by  errors  of  refraction. 

2.  Inequality  in  the  vision  of  the  two  e^'es,  or  amblyopia  of  one 
eye.  which  removes  the  natural  stimulus  of  diplopia  to  exact  conver- 
gence. 

3.  Disturbances  of  innervation  and  defective  development  of  the 
fusion  faculty. 

These  causes  of  squint  are  somewhat  elaborated  in  the  succeeding 
paragraphs. 

1.  Disturbances  in  the  Relations  of  the  Functions  of  Acconunodation 
and  Convergence. — The  relation  between  these  two  functions  has  been 
previously  described  (see  page  46).  Some  latitude  of  movement  is 
possessed  by  each  function  separately;  but  a  limit  to  the  independent 
exercise  of  either  function  exists,  beyond  which  neither  function  can 
operate  alone.  Thus,  a  hyperopia  of  6  D  would  require  an  accommo- 
dation of  6  D  to  neutralize  it,  the  visual  lines  being  parallel.  This  is 
rarely  possible;  some  meter-angles  of  convergence  will  usually  accom- 
pan}'  the  accommodative  effort.  The  point  of  convergence  is  then 
nearer  than  the  point  accommodated  for,  constituting  a  convergent 
squint.  Hyperopia,  is  therefore,  frequently  accompanied  by  conver- 
gent squint. 

In  contrast  to  this,  a  myope  of  10  D  requires  10  meter-angles  of 
convergence  to  see  at  his  far  point  of  vision,  that  is,  the  point  at  which 
he  can  see  with  relaxed  accommodation.  This  is  not  usualh'  possible, 
because  the  enormous  convergence  necessary  to  see  at  this  point  is  too 
severe  a  strain;  consequently,  the  visual  lines  intersect  at  a  greater 
distance  than  the  point  for  which  they  are  accommodated,  and  bin- 
ocular vision  is  abandoned.  The  eyes,  left  to  the  preponderating 
forces,  assume  the  direction  seen  during  sleep  and  deep  anesthesia — 
viz.,  divergence.  Myopia  is,  therefore,  frequently  accompanied  by 
divergent  squint. 

Sometimes  individuals  possess  or  acquire  unusual  power  in  develop- 


598    MOVEMENTS   OF   THE    EYEBALLS   AND   THEIR   ANOMALIES 

ing  one  or  other  of  these  two  functions.  Thus,  the  hyperope  ma}'  de- 
velop his  accommodation  sufficiently  to  equalize  the  disparity  in  the 
refraction  and  thus  avoid  squinting.  The  myope  may  also  develop 
his  convergence  beyond  the  usual  amount  so  as  to  prevent  divergence. 
Hence  all  hyperopes  do  not  have  convergent  squint;  neither  do  all 
myopes  have  divergent  squint. 

2.  Inequality  in  the  Vision  of  the  Two  Eyes,  or  Amblyopia  of  One  Eye, 
Which  Removes  the  Natural  Stiiyiulus  of  Diplopia  to  Exact  Convergence. — 
Amblyopia  of  the  squinting  eye  is  present  in  a  large  proportion  of  the 
cases  of  concomitant  convergent  strabismus,  or,  more  accurately,  the 
amblyopia  of  the  squinting  eye  exceeds  that  of  the  other.  Whether 
this  amblyopia  is  a  cause  or  a  consequence  of  the  squint  has  given  rise 
to  two  theories.  According  to  one  theory,  advocated  by  Donders  and 
others,  the  squint  causes  the  amblyopia  which  depends  upon  a  loss  of 
vision  due  to  habitual  suppression  or  to  lack  of  use  of  the  squinting 
eye — amblyopia  exanopsia — or,  according  to  Hirschberg's  terminologj', 
amblyopia  exablepsia.  According  to  the  other  theory,  advanced  by 
Schweigger,  the  amblyopia  is  a  congenital  defect  which  precedes  and 
causes  the  squint.  Priestley  Smith  points  out  that  all  eyes  are  ambly- 
opic at  birth,  and  reach  the  normal  standard  of  vision  only  after  several 
years.  If  strabismus  is  established  before  this  standard  is  attained, 
further  visual  progress  of  the  squinting  eye  is  likely  to  be  hindered  or 
even  arrested. 

Ophthalmoscopically  these  amblyopic  or  so-called  ''neglected  eyes" 
may  be  entirely  normal,  or  there  may  be  at  times  distinct  changes  in 
and  around  the  nerve-head  and  in  the  macula.  Central  scotomas  and 
contraction  of  the  visual  field  are  sometimes  demonstrable,  as  the 
author  has  shown,  and  in  such  circumstances  these  eyes  are  not  sus- 
ceptible of  improvement  in  vision  (see  also  page  545). 

An  amblyopia  which  removes  the  stimulus  of  diplopia  to  exact  con- 
vergence may  also  include  cases  in  which  the  visual  acuteness  is  di- 
minished by  refractive  differences  in  the  two  eyes,  one  eye  Inking 
greatly  inferior  to  its  fellow  by  reason  of  a  high  degree  of  hj-peropia  or 
myopia,  with  or  without  astigmatism,  by  opacities  in  the  media  of  one 
eye  (especially  corneal  opacities),  bj'  congenital  cataract,  and  by  com- 
plete blindness.  The  failure  to  recognize  diijlopia  causes  the  visual 
axes  to  vary  considerably  either  toward  convergence  or  divergence, 
without  appreciation  of  this  on  the  part  of  the  patient.  If  the  eyes  are 
hyperopic,  they  are  apt  to  converge;  if  myopic,  to  diverge.  Numerous 
cases  of  squint  exist  without  anildyopia.  and  the  rcfrtiction  of  both 
eyes  may  be  ecjual. 

3.  Disturbances  of  Innervation  and  Defective  Development  of  the 
Fusion  Faculty.— Accordinfr  to  Hansen  (5rut,  "convergent  strabismus 
originates  and  continues  as  the  result  of  an  innervation  which  effects 
in  the  interni  a  shortening  cxct'cthng  in  amount  tliat  which  is  desiral)le. 
Divergent  stral)isnnis  is  tlic  expression  for  a  relaxation  of  convergence 
innervation,  which  permits  the  eye  to  take  up  its  anatomic  position  of 
rest."     Accor(Hng  to  Priestley  Smith,  "conv(>rgent  stialiisnuis  is  a  dis- 


i 


CONCOMITANT    STRABISMUS    OR    SQUINT:    HETEROTROPIA    599 

order  of  innervation  in  which  the  visual  centers  fail  to  control  the  act 
of  convergence,  which  is  degraded  and  becomes  automatic.  It  is  excited 
by  the  act  of  accommodation  and  is  excessive  because  uncontrolled. 
The  failure  of  control  depends  largely  upon  faulty  development  of  the 
visual  apparatus.  Hj^peropia,  when  of  considerable  degree,  predis- 
poses to  strabismus  by  demanding  an  abnormal  effort  of  control.  The 
disorder  is  confirmed  and  perpetuated  by  suppression  of  the  function 
of  the  squinting  eye." 

i^.ccording  to  Claud  Worth,  "when  the  fusion  faculty  is  fairly  well 
developed,  neither  hyperopia,  anisometropia,  nor  heterophoria  can 
cause  squint.  In  fact,  then,  nothing  but  an  actual  muscular  paralysis 
can  cause  an  eye  to  deviate,  in  which  case  the  resulting  diplopia  is 
intolerable.  Sometimes,  however,  owing  to  a  congenital  defect  the 
fusion  faculty  develops  later  than  it  should,  or  it  develops  very  im- 
perfectly, or  it  may  never  develop  at  all.  Then,  in  this  case,  there  is 
nothing  but  the  motor  coordinations  to  preserve  the  normal  relative 
directions  of  the  eyes,  and  anything  which  disturbs  the  balance  of 
these  coordinations  will  cause  a  permanent  squint.  Thus,  the  essential 
cause  of  squint  is  a  defect  of  the  fusion  faculty."  The  provocation  in 
the  presence  of  this  fundamental  cause  to  squint  may  be  supplied,  he 
believes,  by  various  conditions — for  example,  hj^peropia,  anisometropia, 
heterophoria,  amblj'-opia  of  one  eye,  certain  eruptive  fevers  and  infec- 
tions (whooping-cough,  especially  if  hyperopia  in  anj' degree  is  present) , 
violent  mental  disturbance,  and  hereditary  influence.  The  influence 
of  heredity  in  squint  is  an  important  matter,  and  Mr.  Worth  believes, 
and  this  certainly  is  in  accord  with  the  author's  experience,  that  a 
history  of  heredity  can  be  obtained  in  fully  50  per  cent,  of  the  cases. 
Therefore  it  is  important  carefully  to  investigate  early  in  life  the  eyes 
of  children  whose  parents  or  grandparents  have  squinted. 

A  predisposition  to  strabismus  may  arise  on  account  of  the  size  and 
shape  of  the  eyeball  and  orbit.  A  narrow,  horizontal  diameter  of  the 
face  might  predispose  to  convergent  strabismus,  or  an  unusually  broad 
diameter  to  divergent  strabismus.  These  conditions  may  coexist 
with  hyperopia  and  myopia.  A  very  short  eyeball,  flattened  in  its 
anteroposterior  direction,  by  its  greater  facility  of  movement  would 
render  convergence  easier; the  oppposite  condition — namely,  elongation 
of  the  anteroposterior  axis  of  the  ej^eball — would  render  this  movement 
more  difficult.  An  unusual  value  of  the  angle  gamma  might  create  a 
disposition  to  squint  by  disturbing  the  relation  between  convergence 
and  accommodation.  At  one  time  disparity  in  the  length,  thickness, 
and  tension  of  opposing  muscles  was  regarded  as  an  important  factor 
in  the  development  of  squint. 

Single  Vision  in  Concomitant  (Comttant)  Strabismus. — Diplopia  is 
rarely  noticed  in  comitant  convergent  strabismus,  because  the  deviating 
eye  involuntarily  suppresses  the  image,  or  else  has  learned  to  disregard 
it. 

Suppression  of  the  image  is  not,  however,  habitually  permanent,  or 
suppression  does  not  extend  over  the  whole  visual  field,  and  many 


OnO    MOVEMENTS    OF   THE    EYEBALLS    AND    THEIR    ANOMALIES 

patients  can  be  made  conscious  of  diplopia  if  a  red  jjlass  or  cobalt  glass 
is  placed  before  one  eye  and  a  prism  before  the  other.  When  the 
squint  is  very  large  it  may  be  necessary  to  correct  the  greater  part  of  it 
with  prisms  liefore  diplopia  is  manifest.  If  prisms  and  the  red  glass 
fail,  Schwcigger's  test  is  as  follows:  A  flame  is  placed  to  one  side  of  and 
behind  the  squinting  eye,  and  its  image  is  thrown  into  this  eye  with  a 
plane  glass  held  close  to  it.  When  the  reflex  reaches  the  center 
of  the  pupil  the  patient  sees  it  and  can  describe  its  relation  to 
the  image  of  another  flame  o])served  by  the  fixing  eye  at  a  distant 
point.  With  high  degrees  of  amblyopia  it  may  l)e  impossil)le  to  pro- 
duce diplopia. 

In  comitant  divergent  squint,  especially  of  low  degree,  antl  in  the 
convergent  strabismus  of  myopes,  diplopia  is  not  uncommon;  also  in 
moderate  degrees  of  convergent  strabismus  and  in  the  residual  squint 
after  tenotomy.  Referring  to  the  nature  of  diplopia  in  comitant 
strabismus  Claud  Worth  thus  expresses  himself:  The  subject  of  squint 
with  diplopia  sees  with  his  deviating  eye  a  faint  eccentrically  placed 
image  of  the  object  to  which  the  fixing  eye  is  directed,  and  suppresses 
the  image  of  the  oljject  which  lies  in  the  axis  of  the  deviating  eye — /.  e., 
he  sees  two  images  of  the  same  ol)ject,  but  not  two  different  objects. 

Sometimes  after  operation,  as  was  first  noticed  by  von  Graefe,  the 
diplopia  is  anomalous  or  paradoxic,  as  it  is  called — that  is,  there  is 
crossed  dii)lopia  with  convergent  squint.  Javal  observed  and  studietl 
the  same  phenomenon  in  stral)ismic  patients  upon  whom  no  operation 
had  been  performed.  It  has  ])een  explained  on  the  theory  tiiat  there 
has  been  developed  in  the  squinting  eye  a  spot  identical  with  the  macula 
lutea  of  the  straight  eye,  or  that  there  has  been  developed  what  has 
been  named  a  vicarious  fovea.  According  to  Tscherning.  in  certain 
cases  of  strabismus  a  period  may  be  leached  after  operation  when  the 
patient  localizes  with  reference  both  to  the  new  and  the  old  fovea,  the 
result  being  binocular  triplopia,  a  name  given  by  Javal  to  the  phenom- 
enon. Verhoeff  thinks  paradoxic  diplopia  "is  due  not  to  the  develop- 
ment of  a  new  system  of  corresponding  points.  i)ut  to  an  absence  of  any 
such  system  whatever,  so  that  when  diplopia  is  i)r(Hluced,  each  eye 
localizes  its  image  with  regard  to  itself  alone  and  hence  more  or  less 
correctly." 

Measurement  of  Strabismus.  1.  S(iuint  may  i)e  measured  approxi- 
mately l)y  tlic  deviation  inward  of  the  i)upil  of  one  eye  while  the  other 
eye  fixes  an  ol)ject.  The  pupil  being  situated  10. o  nun.  in  ailvance  of 
the  center  of  rotation,  its  deviation  inward  or  outward,  measured  on  a 
rul(!,  represents  the  tangent  of  the  angle  of  the  scpiint.  A  ileviation  of 
1  mm.  represents  a  scpiint  of  0°.  Tor  this  purpose  an  or«linary  rule 
divided  into  millimeters  may  be  employeil,  or  a  specially  devised  in- 
strument curvetl  to  adapt  itself  to  the  (•ur\-e  of  tiie  eyeball  and  known 
as  a  strahi.sotnctcr. 

If  diplopia  is  present,  as  Landolt  lias  shown,  it  |)ennits  an  accurate 
determination  of  the  angle  ot  st  rabisiuus.  '['he  piocedure  nia>'  be  as 
follows: 


CONCOMITANT    STRABISMUS    OR    SQUINT:    HETEROTROPIA    601 

Upon  a  wall  of  the  consulting  room,  in  a  horizontal  line,  and  so  as  to  be  on  a 
level  with  the  eyes  of  the  patient,  who  is  about  3  meters  froni  the  wall,  are  perma- 
nently marked  out  tangents  of  angles  of  5°  each,  as  seen  from  the  place  where  the 
squinting  eye  is.  Exactly  opposite  to  the  squinting  eye  is  0°,  while  toward  the  right 
and  left  the  points  are  marked  up  to  45°  or  more.  The  flame  of  a  candle  being  held 
at  0°,  and  one  eye  of  the  patient  being  covered  with  a  red  glass,  he  is  called  on  to 
indicate  the  position  of  the  image  belonging  to  the  squinting  eye,  and  the  number 
on  the  wall  which  corresponds  to  this  gives  the  angle  of  the  strabismus. 

In  these  circumstances  the  degree  of  prism  necessary  to  fuse  the 
double  images  may  be  used  to  measure  the  squint. 

2.  Angular  Method. — The  perimeter  may  be  employed  to  mea- 
sure squint  with  reasonable  accuracy,  although  Worth  condemns  the 
method  because  it  takes  no  account  of  the  angle  gamma.  Landolt 
thus  describes  the  method: 


Fig.  256. — Measurement  of  squint  ■«-ith  a  perimeter. 

The  deviating  eye,  R,  is  placed  at  the  center  of  the  graduated  arc  of  the  perimeter. 
P-P,  the  arc  lying  on  the  plane  of  the  deviation.  The  patient  is  then  required  to  fix 
with  his  two  eyes  a  distant  object.  A,  situated  at  the  central  radius,  R-o-A.  This  is 
the  direction  which  the  deviating  eye  should  have  in  the  normal  condition.  The 
point  n,  to  which  the  eye  in  reality  is  directed,  should  now  be  determined;  the  angle 
o-R-n,  formed  by  the  deviating  visual  line  «,  with  the  normal  line  of  fixation  A-a-R, 
is  the  angle  of  (he  strabismus.  In  order  to  obtain  this  direction  (i.  e.,  the  point  n  at 
which  the  eye  is  directed)  it  would  be  necessary  only  to  determine  the  visual  axis. 
As  this  is  not  an  easy  matter,  it  is  sufficient  in  practice  to  be  contented  with  the 
optical  axis;  this  differs  from  the  former  only  by  the  angle  gamma,  which,  in  com- 
parison with  the  large  angle  of  the  strabismus,  may  be  neglected.  The  flame  of  a 
candle  is  moved  along  the  arc  of  the  perimeter  until  its  reflexion  is  in  the  center  of 
the  pupil.  This  will  occur  when  the  flame  is  at  n.  The  optical  axis  has  now  been 
found,  and  the  size  of  the  angle  of  strabismus  may  be  read  off. 

Priestley  Smith's  Tape  Method. — This  is  a  very  good  method,  although  it  is 
not   very  readily  applied  to  young  children.     Worth  describes  it  as  follows:  "A 


602    MOVEMENTS   OF   THE   EYEBALLS   AND   IHEIR   ANOMALIES 

string  1  meter  loriK  has  a  ring  at  one  end.  To  the  rin?  is  attached  a  graduated 
tape.  The  tape  has  a  weight  at  its  other  end.  Tlie  patient  holds  the  free  end  of 
the  string  against  his  temple.  The  surgeon  puts  the  ring  on  a  finger  of  one  of  his 
hands,  in  which  he  holds  an  ophthalmo.'cope  mirror.  The  tape  is  allowed  to  slide 
between  the  fingers  of  the  other  hand,  the  weight  keeping  the  tape  taut.  The 
patient  is  first  told  to  fix  the  mirror,  while  the  light  of  a  lamp  is  reflected  into  the 
fi.xing  eye.  The  position  of  the  image  of  the  mirror  on  the  cornea  of  the  fi.xing  eye 
is  noted.  The  light  from  the  mirror  is  now  thrown  on  to  the  deviating  eye,  and 
the  patient  is  directed  to  look  at  the  surgeon's  tape  hand.  This  is  moved  horizon- 
tally till  the  position  of  the  image  of  the  mirror  on  the  cornea  of  the  squinting  eye  is 
similar  to  that  which  it  formerly  occupied  on  the  cornea  of  the  fi.xing  eye.  The  string 
keeps  the  ophthalmoscope  hand  at  1  meter  from  the  patient's  eye.  The  observer 
keeps  the  tape  hand  as  nearly  as  possible  at  the  same  distance  from  the  patient's 
eye.  The  graduated  scale  on  the  tape,  where  it  slides  through  the  tape  hand,  shows 
approximately  the  angle  of  the  deviation  in  degrees." 

Various  forms  of  "  deviometers  "  have  been  devised  for  measuring 
strabismus,  especially  by  Nelson  Black  and  by  C.  Worth. 

Treatment  of  Concomitant  (Comitant)  Strabismus. — A.  Convergent 
Concomitant  Strabismus. 

1,  Spectacle  Treatment. — Glasses  which  neutralize  the'  refractive 
error  should  be  ordered  for  every  patient  with  convergent  comitant 
scjuint  after  the  use  of  atropin  has  thoroughly  paralyzed  the  function  of 
the  ciliarj'  muscle.  In  the  majority  of  cases  the  refraction  is  hyperopic 
and  is  often  associated  with  considerable  degrees  of  astigmatism. 
There  is  no  difficulty  in  estimating  exactly  the  proper  lenses  by  means 
of  retinoscopy,  and  if  they  are  persistently  worn  early  enough — before 
the  fifth  year — and,  in  addition,  fusion-training  is  carried  on.  the 
strabismus  will  be  cured  in  a  very  considerable  percentage  (variously 
estimated  from  30  to  70  per  cent.)  of  the  cases.  It  is  important  that 
this  non-operative  treatment  of  squint  should  be  begun  as  soon  after 
the  discovery  of  the  condition  as  possible,  and  glasses  may  usually 
be  adjusted  when  the  child  is  three  years  old;  often  even  earlier. 

Prolonged  atropinization  of  both  eyes  of  very  young  children  with 
scjuint,  in  order  to  remove  the  abnormal  stinuilus  to  convergence  which 
results  from  overaction  of  the  ciliarj-  muscle,  was  at  one  time  a  much 
recommended  method  of  treatment.  As  Worth  points  out.  while  it 
may  produce  temporary  improvement,  or  even  disappearance  of  the 
strabisnuis,  it  tends  to  increase  tlie  am])lyopia  of  the  deviating  eye.  and 
is,  therefore,  a  thciapeulic  measure  to  l)e  condemned.  He  properly 
recommends  atropinization  of  the  fixing  eye  only,  so  that  the  child 
shall  acquire  the  habit  of  using  the  better  (atropinizcd)  eye  for  distant 
vision,  and  the  poorer  (imatropinized)  eye  for  close  vision,  anil  thus 
avoid  amblyopia  from  disuse.  Suilal)l('  glasses  shoiiUl  l)e  worn.  If  the 
visual  acuteness  rises  sufficiently,  so  that  the  originally  deviating  vyo 
liecomes  the  .squinting  eye,  the  drug  nmst  be  discontimieil.  and.  if  the 
original  condition  repeats  itself,  be  used  carefully  and  intermittingly ; 
for  (ixample.  for  a  few  days  dtn-ing  each  month  (Worth).  Hel)er  rec- 
ommended invisible  ))ifocal  lenses  in  tiie  treatment  of  esotropia  in 
little  children,  a  sphere  of  2  to  H  I)  being  added  to  the  correcting  lenses, 
the  idea  being  "to  set  the  spasti<'  aecommodat ion  apparatus  at  rest." 


CONCOMITANT    STRABISMUS    OR    SQUINT:    HETEROTROPIA    603 

A  0.5  per  cent,  solution  of  atropin  is  used  once  daily  for  two  months; 
at  the  end  of  this  time  it  is  discontinued.  A  similar  recommendation 
has  been  made  by  Linn  Emerson.  These  recommendations  are  in 
practical  accord  with  methods  previously  advocated  by  Theobald. 
Accordina:  to  Duane  accommodative  insufficiency  is  more  often  asso- 
ciated with  insufficiency  of  convergence.  Rarely,  however,  in  his 
experience,  persistent  convergence  excess  is  not  relieved  by  wearing 
the  full  correction  for  distance  and  near.  In  such  circumstances  the 
"bifocal  treatment"  may  afford  relief. 

2.  Educative  Treatmeni. — This  includes  occlusion  of  the  eye  by 
means  of  a  shade  or  'pad,  bar  reading,  orthoptic  training,  and  develop- 
ment of  the  fusion-sense. 

(a)  Occlusion  of  the  Fixing  Eye. — The  sound  eye  should  be  covered 
with  a  shade  or  bandage,  not  so  much  with  the  hope  of  improving  the 
acuteness  of  vision  of  the  deviating  eye,  but,  as  Priestley  Smith  has 
said,  to  compel  it  to  use  such  vision  as  it  has  to  promote  fixation,  and  to 
prevent  or  stop  the  habit  of  suppression.  If  the  child  wears  spectacles, 
as  it  should,  a  blinder  of  gutta-percha  may  readily  be  adjusted  on  the 
lens  in  front  of  the  fixing  eye.  If  the  vision  of  the  squinting  eye  is  very 
imperfect,  it  is  permissible  during  this  treatment  to  wear  the  patch  on 
this  eye  instead  of  the  sound  one  for  a  few  hours  each  day;  but  both 
eyes  should  not  be  allowed  to  be  uncovered  at  the  same  time.  Occlu- 
sion of  the  fixating  eye  is  a  method  of  real  value.  Naturally,  the 
earlier  it  is  used  and  the  more  persistently  it  is  employed  the  better 
will  be  the  results. 

(h)  Orthoptic  Training. — This  consists  of  the  establishriient  of 
diplopia  and  training  the  eyes  to  fuse  the  double  images,  and  is  a 
method  of  treatment  of  squint  which  was  especially  advocated  by  Javal. 
It  is  particularly  suited  to  moderate  degrees  of  strabismus  and  to 
residual  squint  after  operation.  It  requires  considerable  care  and 
patience  properly  to  carry  out  the  details.  In  order  to  educate  the 
fusion  faculty  the  stereoscope  should  be  employed.  The  patient's 
ametropia  having  been  fully  corrected,  the  exercises  may  be  per- 
formed according  to  the  method  given  by  Landolt,  as  follows : 

In  an  ordinary  box-stereoscope,  in  the  place  of  "views,"  two  objects  of  some 
very  simple  shape  are  introduced — for  instance,  two  vertical  lines,  one  above  and 
the  other  below  the  same  horizontal  line.  These  two  lines,  which  may  be  brought 
toward  or  removed  farther  from  each  other  at  will,  are  placed  at  a  distance  about 
equal  to  that  between  the  two  eyes.  In  such  circumstances  their  fusion  into  a 
single  vertical  line  necessitates  parallelism  of  the  lines  of  fixation.  This  parallelism 
is  generally  possible  only  in  the  absence  of  any  accommodative  effect.  Hence  the 
sight-holes  of  the  stereoscope  are  provided  with  -}-  6  D  lenses  (the  length  of  the 
ordinary  stereoscope  being  16  cm.),  which  permit  the  subject  to  see  at  the  distance 
of  the  objects  without  exercise  of  the  accommodation. 

The  majority  of  patients  do  not  succeed  in  fusing  the  images  when  their  eyes 
are  directed  in  a  parallel  direction.  These  latter  generally  show  a  certain  conver- 
gence. The  patient  is  then  taught  to  find  the  distance  between  the  two  objects 
which  is  requisite  for  the  fusion  of  their  images.  When  this  is  accomplished,  the 
two  objects  are  gradually  separated  more  and  more  in  successive  sittings  until 
fusion  is  effected  without  the  least  convergence. 


604    MOVEMENTS    OF   THE    EYEBALLS    AND    THEIR    ANOMALIES 

When  binocular  vision  is  obtained,  with  parallelism  of  the  lines  of  fixation, 
which  is  equivalent  to  binocular  vision  at  a  distance,  an  attempt  should  be  made 
to  realize  it  for  a  point  which  requires  a  certain  degree  of  convergence.  To  pro- 
voke a  convergence  of  1  meter-angle,  the  objects  are  brought  together  through  a 
distance  varying  with  the  base  line,  the  average  being  about  1  cm.  In  order  to 
make  the  patient  furnish  an  amount  of  accommodation  equivalent  to  this  amount 
of  convergence,  the  strength  of  the  convex  lens  is  diminished  1  diopter.  The 
trials  are  continued  in  this  way  until  the  two  objects  are  brought  on  a  vertical  line. 
At  this  moment  they  require,  for  their  binocular  fixation,  a  convergence  of  6  meter- 
angles  and  an  accommodation  of  (3  D.  .\n  emmetrope  would,  therefore,  have  to 
remove  the  glasses  from  the  stereoscope  and  see  with  the  naked  ej'e;  an  ametrope 
would  require  simply  the  correction  of  his  refractive  defect. 

The  illumination  of  the  object  looked  at  by  the  deviating  eye  may 
bo  increased  in  order  to  reinforce  its  visual  impressions,  as  in  Landolt's 
new  stereoscope. 

If  the  angle  of  squint  is  very  great,  both  eyes  cannot  look  at  the 
same  time  into  an  ordinary  stereoscope,  and  therefore  a  number  of 
excellent  instruments  have  been  devised  which  can  be  adapted  to  the 
angle  of  squint.  Kroll's  orthoptic  exercises,  arranged  by  Perlia,  which 
consist  of  colored  plates  placed  in  a  suitable  stereoscope,  are  useful.  In 
many  respects  with  the  instrument  devised  by  Claud  Worth,  to  which 
he  has  given  the  name  amhlyoscope,  the  most  satisfactory  results  are 
achieved,  and,  as  this  accomplished  surgeon's  method  is  now  so  much 
employed,  the  following  directions  have  been  written  at  the  author's 
request  by  a  member  of  his  staff,  Dr.  H.  !Maxw(»ll  Langdon,  who  has 
devoted  nmch  attention  to  these  exercises: 

The  amblyoscope  consists  of  two  tubes,  one  for  either  eye,  each  having  its  own 
illumination,  which  can  be  increased  or  lessened  so  as  to  equaU^e  the  visual  impres- 
sions in  case  one  eye  is  amblyopic.  An  object-slide  is  placed  in  the  objective  end  of 
each  tube,  and  is  reflected  in  a  mirror  at  the  bend  of  the  tubes,  which  is  placed  at 
the  focal  di.stance  of  convex  lenses  fitted  in  the  i)roxinial  ends  of  the  tubes,  so  that 
no  accommodation  is  necessary.  The  proximal  ends  of  the  tubes  are  hinged  in  sucli 
a  manner  that  thej'  may  be  adapted  to  a  convergent  strabisnuis  of  ()0°  or  a 
divergent  strabi.smus  of  30°. 

The  child's  vision  should  be  testetl,  if  types  or  other  signs  cannot  be  utilized, 
with  small  white  ivory  balls,  each  with  a  diameter  varying  from  'o  to  1*2  inch. 
Each  eye  is  tried  separately,  and  the  child  is  recjuired  to  pick  up  the  ball,  which  is 
rolled  with  a  twisting  movement.  If  this  test  reveals  that  one  eye  is  amblyojjic  and 
possesses  one-sixth  or  less  of  visual  acuteness,  some  form  of  blinder  exerci.se  should 
be  instituted  to  improve  the  defective  visual  acutene-ss  (.see  page  tiOo).  Preceding 
the  exercises  with  the  amblyoscope,  the  angle  of  strabismus  should  be  mejisured 
according  to  the  methods  cLsewhere  described,  the  refractive  error  having  been 
carefully  and  fully  corrected,  and  the  glas.ses  being  in  position,  and  during  ."ill  of 
these  exercises  the  gla.sses  nuist  be  worn.  Amblyoscope  training  should  In-  begun 
as  soon  as  the  child  is  old  enough  to  look  at  ordinary  j)ictures  and  to  talk  about 
them,  l)ecause  deviation  yields  far  more  readily  to  tlu'se  exerci.ses  in  young  chil- 
dren than  in  older  ones,  and,  moreover,  after  the  sixth  year  it  is  usually  practically 
impossible  to  make  any  satisfactory  impression  upon  the  defective  fusion  faculty. 
A  chilli  of  three  yeaix  is  well  able  to  tak*-  part  m  these  exercis«'s,  especially  if  they 
are  so  coiulucted  that  they  represent  to  him  a  ganu'  in  which  he  may  readily  l)e 
interested.  Tsually  one  or  two  sittings  a  week,  each  occupying  half  an  hour,  are 
sufficient.  The  child  should  be  seated  on  a  chair  between  the  surgeon's  knee.s, 
and  the  angle  of  the  tubes  approximaU'd  to  the  angle  of  strabismus.  Next,  the 
illuniiiiiition,   which   may  c(»nsist   of  two  electric-light    buliis.   two  lamps,  or    two 


CONCOMITANT    STRABISMUS    OR    SQUINT:    HETEROTROPIA    605 

candles,  equally  distant  from  each  tube,  are  arranged,  and  an  object-slide  is  placed 
in  each  holder.  These  object-slides  should  consist  of  pictures  familiar  to  young 
children,  but  the  ones  used  at  first  should  be  quite  dissimilar;  for  example,  the 
picture  of  a  bird  and  the  picture  of  a  cage.  The  child  is  now  required  to  look  into 
the  tubes,  and  is  asked  what  he  sees.  If  one  eye  is  amblj^opic  to  any  considerable 
degree,  it  is  probable  that  the  image  of  the  object  before  the  better  or  fixing  eye 
will  be  the  only  one  which  is  visible.  Hence,  the  illumination  must  be  altered 
before  the  other  object-slide  can  be  seen  by  diminishing  the  light  before  the  fixing 
or  better  eye,  and  increasing  that  before  the  amblyopic  or  squinting  eye,  continuing 
with  this  regulation  of  lights  until  both  objects  are  visible  and  can  be  described 
by  the  child.  This  alteration  in  the  lights  can  be  accomplished  in  various  ways; 
for  example,  by  changing  the  distance  of  the  lights,  as  Mr.  Worth  suggests,  or  by 
adapting  to  the  amblyoscope,  as  the  writer  has  done,  a  revolving  wheel,  which 
contains  smoked  lenses  of  different  densities,  and  which  can  be  turned  before  the 
non-amblyopic  eye.     Each  object  should  be  seen  clearly,  and  the  exercise  should 


Fig.  257. — The  Worth-Black  amblyoscope. 


be  varied  with  several  pairs  of  object-slides.  Next,  the  child  is  required  to  place 
one  hand  on  each  of  the  surgeon's  knees  and  to  tap  that  knee  on  the  side  on  which 
the  picture  of  the  bird  is  seen.  If  the  angle  of  the  tubes  is  rapidly  altered  a  position 
will  be  found  where  the  slightest  movement  of  the  tubes  causes  the  picture  of  the 
bird  to  pass  directly  through  from  one  side  of  the  picture  of  the  cage  to  the  other. 
But,  after  continuing  the  exercises,  the  bird  apparently  will  go  directly  into  the 
cage,  indicating  that  the  child  is  acquiring  a  certain  amount  of  fusing  power.  If 
one  object  is  above  the  other,  this  vertical  deviation  must  be  overcome  by  means 
of  prisms  suitably  placed  in  the  grooved  slides  back  of  the  focusing  lenses.  Dr. 
Nelson  M.  Black  has  added  a  vertical  adjustment  to  the  Worth   amblyoscope,  i 

1  The  author  uses,  with  much  satisfaction.  Dr.  A.  Maitland  Ramsay's  (The 
Ophthalmoscope,  January,  1905)  modification  of  Worth's  amblyoscope,  in  which 
totally  reflecting  prisms  are  employed  instead  of  mirrors.  Back  of  eacli  picture 
is  placed  a  small  electric  lamp,  the  relative  brightness  of  which  can  be  varied  to 
any  desired  extent  bj'  shifting  a  key,  which  increases  the  resistance  for  one  of 
the  lamps  while  it  diminishes  it  for  the  other.  The  author  has  slightly  modified 
this  instrument  by  adding  to  it  an  arrangement  by  which  prisms  to  correct  ver- 
tical deviations  may  be  inserted,  and  scales  which  indicate  the  exact  separation 
of  the  tubes  to  suit  the  interpupillary  distance  and  the  degree  to  which  the  tubes 
must  be  converged  or  diverged,  according  to  the  character  and  angle  of  the  squint. 


606    MOVEMENTS    OF    THE    EYEBALLS    AND    THEIR    ANOMALIES 

which  simplifies  the  correction  of  this  deviation  (P'ig.  257).  As  soon  as  the  child 
can  easilj'  merge  the  two  objects,  more  difficult  tasks  are  set,  with  slides  demand- 
ing accurate  and  complete  fusion,  and  by  gradually  widening  the  angle  of  the 
tube,  a  range  of  fusion  which  varies  from  5°  to  15°  may  be  acquired  by  the  patient. 
Finally,  a  series  of  stereoscopic  pictures,  intended  to  teach  the  child  the  sense 
of  perspective,  are  employed.  During  these  exercises,  by  which  the  fusion  faculty 
is  stimulated  and  developed,  the  strabismus  may  do  one  of  three  things:  it  may 
disappear  after  a  few  days  of  training;  it  may  gradually  lessen;  or  it  may  not 
alter  at  all,  and  operative  procedures  are  required  to  produce  parallelism  of  the 
visual  axes. 

These  methods  to  overcome  the  defective  development  of  the 
fusion  faculty  should  be  faithfully  tried  in  spite  of  the  trouble  which 
their  use  entails.  Certainly  the  re-establishment  of  binocular  vision 
in  these  circumstances  is  worth  every  effort. 

(c)  Bar  Reading  {Controlled  Reading  of  Javal). — A  pencil  or,  as 
Priestley  Smith  suggests,  a  thin  strip  of  metal  is  held  midway  between 
the  eyes  and  the  book  which  they  regard.  Reading  can  then  take 
place  without  interruption  only  if  both  eyes  are  employed.  Priestley 
Smith  describes  the  exercises  as  follows:  ''When  the  patient's  fixing 
eye  reaches  that  portion  of  the  line  which  is  hidden  from  it  by  the  bar. 
he  must  use  his  other  eye.  Then  the  fixing  eye  is  covered  for  a  mo- 
ment with  a  screen.  Next,  the  patient  is  taught  to  occlude  it  for  himself 
by  a  momentary  closure  of  the  lids.  Soon  he  will  be  able  to  travel 
along  the  line  with  only  a  slight  hitch  where  he  closes  the  better  eye, 
and  at  last  he  will  read  smoothly,  keeping  both  eyes  open."  The 
method  is  chiefly  effective  when  practised  in  conjunction  with  the  use 
of  the  shade — that  is,  the  shade  covers  the  fixing  eye  antl  it  is  uncovered 
only  for  the  purpose  of  bar  reading;  and  this  should  be  practised  as 
much  as  possible.  Indeed,  according  to  Javal,  the  exercises  must  be 
continued  for  months,  but  there  seems  no  doubt  that  they  are  efficient 
aids  in  the  recovery  of  binocular  vision.  It  need  hardly  be  stated 
that  the  exercises  are  not  suited  to  very  young  children.  They  are 
valuable  in  the  residual  squints  after  operation. 

3.  Operative  treatment  consists  of  tenotomy  of  one  or  both  internal 
recti,  with  or  without  advancement  of  the  externi,  or  of  bilateral  ad- 
vancement of  the  externi  without  tenotomy  of  the  interni  (s(H' page  747). 
If  possible,  operation  should  not  be  undertaken  until  the  fusion  faculty 
has  been  developed  by  the  exercises  already  describeil,  and  in  no  cir- 
cumstances until  the  refractive  error  has  been  fully  corrected  and 
glasses  have  been  worn  for  at  leastf^Six  months.  If,  in  spite  of  such 
treatment,  the  deviation  remains  constant,  operation  is  necessary,  and 
may  be  performed  if  tlie  child  has  pa.ssed  the  sixth  or  seventh  year.  If 
the  exercises  have  failed  to  develop  the  power  of  binocular  fusion,  or  if 
these  exercises  have  begun  at  a  time  too  late  to  expect  this  result,  it 
would  seem  wise,  uinler  most  conditions,  as  Iv  Jackson  insists,  to  wait 
until  the  patient  lias  readied  an  age  when  the  operation  i-an  be  per- 
fcjrmed  under  local  anesthesia  and  inteUigent  co-operation  secureil;  to 
wait,  in  short,  iinlil  .'il'lcr  I  he  pciiod  of  rapid  giowih  and  (h'velopment. 
^\'|)|•lh,  oil  Ihi-  nthcr  hand,  li.as  im  (iliject  ion  to  licniTal  anesthesia. 


CONCOMITANT    STRABISMUS    OR    SQUINT!    HETEROTROPIA    607 

There  is  some  difference  of  opinion  in  regard  to  the  operations  which 
should  be  practised  for  the  rehef  of  convergent  strabismus,  and  each 
case  must  be  carefulh-  studied  before  a  correct  decision  can  be  reached. 
The  practice,  at  one  time  almost  universal,  of  endeavoring  to  correct 
convergent  strabismus  by  means  of  tenotomy-  of  one  or  both  interni, 
according  to  the  amount  of  the  deviation,  has  been  largely  and  very 
properly  abandoned  in  favor  of  advancement  of  the  externi. 

While  it  is  true  that  in  small  squints  (15°  to  20°)  tenotomy  of  the 
internus  of  the  deviating  eye,  if  this  is  not  seriouslj^  amblj^opic,  will 
often  yield,  temporarily  at  least,  a  satisfactory  cosmetic  result  and 
that  in  alternating  squint,  with  good  vision  of  each  eye,  even  a  double 
carefully  performed  tenotomy'  has  been  recommended,  in  most  cir- 
cumstances a  tenotomy  should  be  avoided.  As  Landolt  has  well 
said,  the  "dosage"  of  tenotomy  is  uncertain,  and  from  the  dynamic 
standpoint  its  effects  are  unfavorable.  The  outward  rotation  tends  to 
increase,  the  palpebral  fissure  is  widened,  the  eye  often  is  slight^ 
prominent,  and  inward  rotation  is  permanenth'  weakened.  Free  divi- 
sion of  the  tendinous  insertion  of  the  interni  and  the  surrounding  cap- 
sular attachments  is  7iever  permissible,  and  almost  sure  in  subsequent 
years  to  lead  to  divergence;  indeed,  this  may  be  the  result  of  bilateral 
tenotomies  of  the  interni.  even  if  they  are  carefully  performed.  A.dmir- 
able  results  follow  bilateral  advancement  of  the  interni  close  to  the 
cornea  (tenotomy  is  not  performed),  and  in  pronounced  squint  this 
may  be  combined  with  resection  of  more  or  less  of  the  muscle.  In  this 
respect  the  author  can  confirm  the  value  of  Landolt 's  advice  and 
method,  and  is  in  full  accord  with  Claud  Worth's  condemnation,  under 
most  conditions,  of  tenotomy.  In  slight  degrees  of  squint  simple 
advancement  will  usually  suffice.  After  operation  either  both  eyes 
should  be  bandaged  until  the  sutures  are  removed,  or  both  eyes  should 
be  unbandaged  and  the  patient  from  the  first  directed  to  wear  his 
correcting  glasses.^  (For  the  methods  of  performing  tenotomy  and 
advancement,  see  page  747.) 

B.  Divergent  Concomitant  {Comitant)  Strabismus. — The  relation  of 
divergence-excess  and  convergence-insufficiencj'  to  divergent  strabis- 
mus is  outlined  on  page  611.  A  divergent  squint  may  begin  as  a 
periodic  defect  and  be  gradually  converted  into  a  continuous  defect. 
The  treatment  of  this  form  of  comitant  squint  includes  the  correction 
of  the  error  of  refraction  with  suitable  glasses,  training  convergence, 
and  operative  measures. 

(a)  Glasses  which  neutralize  the  refractive  error  (most  commonly 
myopia  or  myopic  astigmatism  if  convergence-insufficiency  is  the 
predominating  muscular  error)  should  be  adjusted  according  to  the 
rules  which  are  given  in  the  chapter  devoted  to  the  measurement  of 
abnormal  refraction.  H.  Landolt  recommends  concave  glasses  of 
such  strength  that  they  overcorrect  the  myopia.     According  to  him 

1  For  an  important  paper  on  this  subject,  the  reader  is  referred  to  "The  Indica- 
tions for  Operating  in  Heterophoria  and  Squint,"  bv  Alexander  Duane,  Archives 
of  Ophthalmology,  vol.  xl.,  No.  4,  p.  390,  1911. 


608    MOVEMENTS    OF    THE    EYEBALLS    AND    THEIR    ANOMALIES 

the  excessive  effort  of  accoramodation  stimulates  convergence.  Ac- 
cordinp;  to  Woott.f)n  hyperopia  is  much  more  commonly  associated  with 
divergence-excess  than  myopia;  the  reverse  is  true  in  convergence- 
insufficiency  wiiere  myopia  is  the  rule.  In  the  mixed  form,  that  is, 
marked  divergence-excess  and  convergence-insufficiency,  he  finds  that 
anisometropia  is  frequently  present,  myopia  and  hyperopia  being  less* 
commonly  the  associated  refractive  defect.  Naturally,  as  he  admits, 
there  are  exceptions  to  these  rules.  He  doubts  the  value  of  correcting 
glasses  if  divergence-excess  is  the  predominating  error.  Moderate 
degrees  of  divergent  deviation  maj*  often  be  favorably  influenced  by 
prismatic  exercises  (see  page  614). 

(6)  Operative  meosures  depend  entirely  ujwn  the  degree  of  the  de- 
viation, the  vision  in  the  diverging  eye,  and  the  cause  of  the  difficulty. 
When  true  divergent  strabismus  exists,  it  is  usually  necessary  to  per- 
form an  operation  to  correct  it.  This  maj'  be  either  tenotomy  of  one 
or  both  externi,  or  this  operation  may  be  combined  with  advancement 
of  the  internal  rectus.  Advancement  of  the  interni  is  preferable  to 
tenotomy  of  the  externi  if  there  is  convergence-insufficiency.  Should 
the  condition  be  one  of  divergence-excess  with  hyperopia  tenotomy  of  the 
externi  is  indicated,  indeed,  this  also  obtains  if  myopia  is  present.  A 
coexisting  vertical  deviation  should  be  remedied,  and  some  operators 
(Hansell  and  Re])er)  prefer  to  make  the  vertical  adjustment  before 
attacking  the  lateral  deviation.  The  procedure,  in  some  cases,  abol- 
ishes the  lateral  squint.  Divergent  strabismus  due  to  overcorrection 
following  tenotomy  of  the  interni  should  be  remedied  by  advancement 
of  the  severed  intei'nal  recti  muscles. 

Vertical  Strabismus. — Often  theie  is  an  apparent  vertical  ilevia- 
tion  associated  with  lateral  strabismus,  which  disappears  with  the  cor- 
rection of  the  latter  defect.  In  cases  of  true  vertical  deviation  requiring 
operation  Worth  reconnnends  advancement  of  the  inferior  rectus 
muscle  of  the  eye  which  turns  upward.  Landolt,  although  ojiposinl  to 
tenotomy  of  the  lateral  nuiscles,  does  not  object  to  this  operation  on 
the  superior  rectus.  All  surgeons  agree  that  tenotomy  of  the  inferior 
rectus  usually  is  not  advisable,  except  as  it  may  i)e  performed  to 
compensate  for  the  diplopia  occasioned  by  a  paralysis  of  the  sujierior 
obli(iue  of  the  opposite  eye.  In  certain  circumstances  an  upward 
deviation  is  due  to  spasniodic  action  of  the  inferior  oblique  and  nmst 
be  corrected  by  tenotomy  of  this  muscle  (see  page  74S). 

Results  of  Operation  in  Convergent  Strabismus.  The  efYect  of 
the  operation,  if  well  pcifornied.  is  to  produce  paralli'l  visual  axes,  and 
thus  remove  the  (hsiigiirenicnl .  Properly  speaking,  a  cure  is  obtaiiieil 
only  when  there  is  improvement  in  the  vision  of  the  s(iuinting  eye  and 
binocular  vision  is  secured.  There  has  been  nuich  dilTerence  of  opinion 
on  this  subject,  and  some  authors — for  example,  Lang  and  liarrett  — 
have  (pieslioned  if  valiial)le  inipidvenient  in  the  vision  of  the  aniblyo|)ic 
eve  ever  takes  place.  Binocular  vision  is  secured  in  a  small  numlier  of 
the  cases,  after  correctly  performed  operations  and  after  tlu«  patients' 
eyes  have  IxM'ii  cMrefully  corrected  with  glasses  and  trained  by  orthoptic 


ABNORMAL  BALANCE  OF  OCULAR  MUSCLES,  OR  HETEROPHORIA  609 

exercises.  It  must  be  remembered  as  Duane  points  out,  that  a  patient 
whose  squint  has  been  "cured"  may  have  binocular  fixation,  but  mon- 
ocular vision,  that  is  suppression  of  one  image  continues.  Careful 
training  of  the  fusion  faculty  should  begin  early  and  the  exercises 
already  described  should  be  systematically  carried  out.  Indeed,  as  may 
have  been  inferred,  the  necessity  for  operation,  if  only  the  educative 
treatment  of  strabismus  is  begun  soon  enough,  is  sure  to  diminish, 
but  should  an  operation  become  necessary,  it  is  also  svu-e  to  be  fol- 
lowed by  far  better  results  than  can  be  achieved  in  the  absence  of  such 
training. 

It  is  often  difficult  to  ascertain  whether  true  binocular  vision  exists, 
especially  in  young  children,  and  successful  bar  reading,  usually  quoted 
as  a  sufficient  test,  is,  according  to  Priestley  Smith,  not  without  its 
fallacies.     This  author  tests  as  follows: 

A  reversible  frame  carrying  red  and  blue  glasses  is  placed  in  front 
of  the  patient's  spectacles,  and  he  is  shown,  at  the  reading  distance,  a 
card  with  three  disks  on  a  black  ground,  a  white  one  in  the  middle,  a  red 
one  above,  and  a  blue  one  below.  If  he  can  see  all  three  at  once  and  in 
a  line,  he  is  probably  using  both  eyes  and  fusing  the  two  images  of  the 
white  disk.  If  with  each  eye  alone  he  sees  two,  but  with  both  eyes  three, 
the  proof  is  fairly  positive.  The  test  may  be  improved  by  placing  a 
black  letter  on  each  disk,  which,  if  the  patient  has  sufficient  vision,  he 
should  read.  The  same  test  with  larger  objects  may  be  used  at  longer 
ranges.  The  light  should  be  good,  but  not  too  strong,  and  not  arti- 
ficial. Hering's  drop-test  may  also  be  employed.  A  simple  and  in- 
genious diaphragm  test  for  binocular  vision  has  been  devised  by  N. 
Bishop  Harman.^ 

Spastic  Strabismus. — This  condition,  more  properly  character- 
ized by  the  term  convergence  cramj),  or  spasm  {non-accommodative 
convergence  excess)  is  seen  in  hysteria,  and  is  characterized  by  conver- 
gent squint,  limitation  of  the  motility  of  the  external  recti,  and  by 
homonymous  diplopia.  It  somewhat  resembles  paralysis  of  the  ab- 
ducens,  for  which  it  may  be  mistaken,  but  from  which  it  should  be  dif- 
ferentiated by  a  study  of  the  double  images.  Sometimes  this  form  of 
strabismus  or,  rather,  convergence  spasm  is  associated  with  other 
hysteric  manifestations — l)lepharospasm  and  ptosis — and  may  be  a 
symptom  of  meningitis. 

Abnormal  Balance  of  the  Ocular  Muscles,  or  Heterophoria 
(Latent  Deviation). — This  is,  as  already  defined,  a  disturbance  of  the 
normal  balance  of  the  exterior  eye  muscles,  which  creates  a  tendency 
for  the  visual  lines  to  depart  from  parallelism,  a  tendency  which  is 
checked  by  the  habitual  desire  for  binocular  vision,  or  that  vision  in 
which  the  images  of  an  object  formed  on  the  retinas  of  the  two  eyes 
make  but  a  single  mental  impression. 

Heterophoria  {imbalance,  according  to  Gould)  differs  from  squint 
or  heterotropia  because  in  the  latter  the  fusion  of  the  images  is  usually 
impossible — i.  e.,  binocular  single  vision  is  absent — and  there  is  an  evi- 

1  For  description,  see  Ophthalmic  Review,  vol.  xxviii,  1909,  p.  93. 
39 


610    MOVEMENTS    OF   THE    EYEBALLS    AND    THEIR    ANOMALIES 

dent  departure  of  the  visual  lines  from  parallelism,  which  gives  rise  to 
the  term  which  dcsifrnates  the  condition. 

Causes. — -Inil):tlance  of  the  ocular  muscles  may  be  due  to:  (a) 
weakness  of  the  muscles  (properly  called  insufficiency)  of  congenital 
origin,  or  depending  upon  a  general  lack  in  muscular  tone,  the  result  of 
anemia,  nervous  exhaustion,  pelvic  disorders,  etc.,  or  malaria,  rheuma- 
tism, gout,  etc.,  diseases  wliich,  however,  may  also  be  potent  by  affect- 
ing not  the  muscles' themselves,  but  their  innervation;  (b)  errors  of 
refraction  and  disturbance  of  accommodative  efforts  {a^cotmnodative 
heterophoria) ;  (c)  the  anatomic  arrangement  of  the  parts — for  example, 
faulty  attachment  of  the  muscle  {comitant  heterophoria);  (d)  excessive 
action  or  spasm  of  opposing  and  dominating  muscles  (spast)iodic 
heterophoria);  (e)  disturbances  of  innervation  {central  heterophoria); 
and  (/)  a  paretic  condition  of  the  muscle  (paretic  heterophoria  of 
Duane). 

Varieties. — According  to  Stevens'  nomenclatur(\  if  there  is  a  tend- 
ing of  the  visual  lines  in  parallelism,  the  term  orO.ophoria  is  applied; 
if  there  is  a  tending  of  these  lines  in  some  other  direction,  the  term 
heterophoria  is  employed.  Heterophoria  is  divided  into:  esophoria,  a 
tending  of  the  visual  lines  inw^ard;  exophoria,  a  tending  of  the  visual 
lines  outward;  hyperphoria  (right  or  left),  a  tending  of  the  right  or  left 
visual  line  in  a  direction  above  its  fellow.  Cyclophoria,  according  to 
Savage,  is  a  want  of  equilibrium  on  the  part  of  the  oblique  muscles 
(see  also  page  78). 

Abnormal  inward  tending  of  the  visual  lines  may  depend  upon 
excessive  convergence  or  deficient  divergence,  or  upon  these  conditions 
combined.  Duane^  desciibes  the  signs  as  follows:  If  esophoria  for  dis- 
tance is  less  than  for  near,  abduction  (prism-divergence)  not  dispro- 
portionately low,  adduction  (prism-convergence)  readily  performed, 
esophoria  marked  at  the  near  point  and  the  convergence  near  point 
excessive,  cotwergence-excess  is  present.  If  esoi)horia  for  distance  is 
much  greater  than  for  near,  abduction  (prism-divergence)  dispropor- 
tionately low  or  absent,  adduction  (prism-convergence)  normal  or  sub- 
normal, esophoria  slight,  absent,  or  replaced  by  exophoria  at  the  near 
point,  and  the  ccjnvergence  near  point  not  abnormally  close  to  the  nose, 
diver(je?icc-i nsufficiency  is  present. 

Convergence-excess  is  followed,  if  of  long  standing,  by  divergence- 
insufficiency,  and  similarly  divergence-insufficiency  by  convergence- 
excess.  In  the  mixed  form  thus  produced  there  are  marked  esophoria 
for  near  and  far,  excessive  approximation  of  the  convergence  near 
point,  and  limited,  absent,  or  negative  alxhiction  (piism-divergence). 
Finally,  the  deviation  ceases  to  be  lat(>iit,  binocular  vision  is  lost,  and 
eso])horia  passes  into  esotro})in. 

Abnormal  outward  tending  of  the  visual  lines  m;i\-  depend  upon 
deficient  convergence  or  excessive  divergence,  or  upon  these  conditions 
combined.     Duane  records  the  symptoms  as  follows:  If  exophoria  for 

'  American  Text-book  of  Diseases  of  the  Eye,  Ear,  Nose,  .-tiid  'I'lnoat,  edited  by 
(Ic  Schwoinitz  and  llandnll.  |)!ip«'  .'il.').  The  descriptions  which  follow  :iri«  con- 
dfiiMcd  fmtii  Diiunc'.s  aitich". 


ABNORMAL  BALANCE  OF  OCULAR  MUSCLES,  OR  HETEROPHORIA  611 

distance  is  slight  or  absent,  abduction  (prism-divergence)  not  very 
great  or  even  subnormal,  adduction  (prism-convergence)  exceedingly 
difficult,  exophoria  marked  at  the  near  point,  and  the  convergence  near 
point  less  than  3  inches  and  maintained  only  for  a  moment,  there  is 
convergence-insufficiency .  Sometimes  this  may  be  so  great  as  to  consti- 
tute a  convergence-paralysis.  If  exophoria  for  distance  is  marked,  ab- 
duction (prism-divergence)  is  high,  adduction  (prism-convergence) 
normal  or  not  greatly  subnormal,  and  the  convergence  near  point 
normal,  there  is  divergence-excess. 

Convergence-insufficiency  is  followed,  if  of  long  standing,  by  diver- 
gence-excess, and,  similarly,  divergence-excess  by  convergence-insuffi- 
ciency. In  the  mixed  form  thus  produced  there  are  marked  exophoria 
for  near  and  far,  excessive  abduction  (prism-divergence),  and  marked 
retreat  of  the  convergence  near  point.  Finally,  the  deviation  ceases  to 
be  latent,  binocular  vision  is  abandoned,  and  exophoria  passes  into 
exotropia. 

If  hyperphoria  varies  noticeably  in  different  directions  of  the  gaze, 
it  is  non-comitant  and  is  due  to  underaction  or  overaction  of  one  or  more 
of  the  elevators  or  depressors;  it  may  be  due  to  spasmodic  action  of 
these  muscles  and  may  spontaneously  disappear.  If  hj^perphoria  re- 
mains the  same  in  all  directions  of  the  gaze,  it  is  comitant,  and  may  be 
due  to  excessive  sursumvergence,  or  more  frequently  to  the  same 
agencies  which  produce  non-comitant  hyperphoria  which  has  become 
comitant. 

Whether  the  hyperphoria  is  due  to  overaction  or  underaction  of  one 
or  other  set  of  muscles  may  be  determined  by  examining  the  rotations 
of  the  eyes  (see  page  575).  Excessive  upward  rotation  would  naturally 
indicate  overaction  of  the  elevators  of  the  hyperphoric  eye,  and  ex- 
cessive downward  rotation  overaction  of  the  depressors.  Deficient 
upward  or  downward  rotation  would  indicate  underaction  of  the  ver- 
tical muscles,  and  in  these  circumstances  diplopia  is  readily  elicited, 
as  it  is  in  paretic  condition,  by  carrying  the  test-light  in  the  direction 
of  the  action  of  the  affected  muscles.  Hyperphoria  usually  does  not 
tend  to  increase,  and  therefore  binocular  fixation  is  usually  retained, 
and  it  is  comparatively  rare  for  hyperphoria  to  pass  into  hypertropia. 

Full  correction  of  hyperopia  disturbs  the  relative  range  of  accom- 
modation and  convergence  and  may  cause  exophoria  (convergence- 
insufficiency — relative  insufficiency  of  the  interni,  according  to  Risley). 
The  same  condition  is  seen  in  myopes  who  do  not  use  glasses  at  close 
ranges  and  in  presbyopes  whose  reading-glasses  are  too  strong.  Suit- 
able glasses,  or  a  modification  of  the  glasses,  and  sometimes  exercises 
with  prisms,  will  relieve  the  condition  (see  also  page  159). 

Relative  Frequency  of  Heterophoria. — Faulty  directing  power  of 
the  vertical  muscles  (hyperphoria)  is  usuall}"  stated  to  be  the  least 
common  of  these  anomalies,  but  is  much  more  frequent  than  was  once 
supposed,  and,  according  to  Hansell  and  Reber,  will  be  found  in  one- 
third  of  the  cases  of  refractive  anomalies.     Many  of  these  hyper- 


612    MOVEMENTS    OF    THE    EYEBALLS    AND    THEIR    ANOMALIES 

phorias,  howovor,  aro  tomporaiy  in  character  and  require  no  treatment 
except  correction  of  tlie  refraction  and  any  underlying;  constitutional 
condition.  The  power  of  hyperphoria  in  causing  asthenopic  symptoms 
is  of  paramount  importance,  and,  according  to  Stevens,  its  role  in  dis- 
turbing the  action  of  the  lateral  muscles  is  significant.  As  measured 
at  the  distant  point  esophoria  is  more  frefjuently  recorded  tiian 
exophoria. 

Difference  Between  Heterophoria  and  Heterotropia  (Squint). — 
The  essential  difference  between  these  two  conditions  has  already  been 
several  times  defined,  and  the  passage  of  a  heterophoria  into  a  hetero- 
tropia has  been  descril)ed.  The  differential  diagnosis  should  depend 
upon  the  results  ol)tained  from  the  application  of  certain  tests.  Duane 
describes  these  as  follows: 

"If  there  is  any  noticeable  deflection  behind  the  screen  (see  page 
74),  the  screen-test  is  applied  in  a  second  way  or  by  binocular-  un- 
covering. This  procedure  consists  in  covering  the  left  eye  and  then 
uncovering  both  ej'^es  and  noticing  the  movement  that  takes  place. 
If,  on  thus  uncovering  the  left  eye,  the  right  eye  remains  steady  and  the 
left  moves  into  position,  the  patient  has  binocular  fixation,  and  the 
deflection  was  a  heterophoria  and  not  a  squint.  If,  however,  the 
right  eye  should  move  out  of  its  position  and  the  left  eye  should  move  in- 
to place,  there  is  a  squint  and  the  left  is  the  fixing  eye.  If  neither  eye 
moves,  there  is  a  squint  and  the  right  is  the  fixing  eye.  By  repeating 
this  experiment  with  each  eye  alternately  the  examiner  can  tell 
whether  thcM'e  is  a  habitual  ))inocular  fixation,  an  alternating  fixation, 
or  a  monocular  squint.  The  diagnosis  between  the  three  may  be  con- 
veniently formulated  as  follows: 

"1.  If  in  binocular  uncovering  hut  one  eye  moves,  heterophoria  and 
not  squint  exists. 

"2.  If  either  both  eyes  move  or,  in  spite  of  there  being  an  evident  de- 
viation, both  eyes  remain  steady,  squint  exists. 

"3.  In  the  latter  case,  if,  when  the  left  eye  is  uncovered,  the  eyes 
behave  in  the  same  way  as  they  do  when  the  right  eye  is  uncovereil 
(both  alike  moving  oi-  both  alike  remaining  steady,  no  matter  whii-h  eye 
is  uncovered),  the  squint  is  alter nalinij. 

"4.  If,  when  one  eye — foi-  instance,  the  right — is  uncov(Mi'd,  l)()th 
eyes  move,  and  when  the  other  e\-e  (in  this  case  the  left)  is  uncovered 
both  <'ves  remain  stea(l>',  the  sciuint  is  monovular  (confined  in  this  case 
to  the  left  eye)." 

Symptoms. — These  are  usually  classified  under  the  gen(Mal  teiin 
inusmlitr  a.slhcuopia,  ;iii(l  \i\-a\  be  dixided  into  t  he  or(//a/- and  the  (/«//( /«»/ 
syujptoms. 

To  the  Jirst  ijioup  beloiig  pain,  often  ovei'  the  insertion  of  the  af- 
fected muscle,  and  especiall>'  m.-iiked  when  t he  eye  is  suddeidy  moveil 
ill  the  diicctioii  of  ils  action;  lilunc(|  \isi(»n  and  imperfect  powiM*  of 
working  at  close  ranges;  in.abihiv  lo  gaz(>  attentively  at  a  statioiuiry 
object  or  person  even  at  long  langes,  and  great  (hscoinfort  when  at- 
tempting lo  \\;itch  nio\ing  olTiccts;  (h'ead  of  light  and  l)leph;nds|)asm, 


ABNORMAL  BALANCE  OF  OCULAR  MUSCLES  OR  HETEROPHORIA  613 

often  confined  to  a  few  fibers  of  the  orbicularis;  and  local  congestions  of 
the  conjunctiva,  especially  over  the  insertion  of  the  muscle,  and  on 
the  margins  of  the  lids.  Often  there  are  eccentric  poses  of  the  head, 
distortions  of  the  features,  especially  wrinkling  of  the  forehead,  con- 
tractions of  the  sternocleidomastoid,  and  tilting  of  one  or  other 
shoulder. 

In  the  second  group  the  prominent  symptom  is  headache,  which  may 
be  situated  in  any  portion  of  the  cranium,  but  which  is  common  in  the 
occiput.  The  pain  may  immediately  follow  the  use  of  the  eyes,  or  be 
delayed,  or  come  on  at  a  certain  hour  of  the  day,  or  even  night.  The 
headache  may  assume  the  migrainous  tj'pe. 

Pain  in  the  back,  especialh'  between  the  shoulder-blades,  or  precor- 
dial pain,  is  common.  Vertigo,  generally  subjective,  is  frequent,  one 
variety  being  characterized  by  a  sense  of  falling  forward  when  walking 
in  a  crowd,  associated  with  confusion  of  ideas.  Drowsiness  and,  on  the 
other  hand,  insomnia  may  be  present,  and  a  varietj'  of  general  or  so- 
called  reflex  neuroses. 

Chorea,  epilepsy,  pseudochorea,  night-terrors,  melancholia,  neuras- 
thenia, hysteria,  palpitation  of  the  heart,  indigestion,  constipation, 
flatulent  dj'spepsia,  and  a  host  of  other  complaints  have  been  attributed 
to  muscular  imbalance,  and  also  to  accommodative  strain,  and  under 
these  conditions  the  ej^es  should  always  be  examined  and  the  ocular 
defects  corrected  (see  also  page  150).  Many  instances  of  remarkable 
nervous  disturbances  are  associated  with  heterophoria,  especially 
hyperphoria  (as  well  as  with  refractive  error),  and  cure  will  often  follow 
the  relief  of  the  ocular  difficulty.  Unfortunately,  the  whole  matter  has 
not  always  escaped  exaggeration. 

Method  of  Examination. — ^The  method  of  examining  the  ocular 
muscles  has  been  fully  described  on  pages  74-80.  (See  also  Appendix, 
page  766.)  Two  points  deserve  reiteration — viz.,  that  a  measurement 
of  the  relative  weakness  and  power  of  the  muscles  is  inexact  unless  this 
has  been  made  after  the  refractive  error  has  been  corrected,  and  the 
muscles  have  been  tested  through  the  correcting  lenses;  and  that  the 
examinations  of  the  muscles  should  be  made  both  for  the  near  and 
the  far  point — i.  e.,  at  30  cm.  and  6  meters — the  latter  being  the 
more  important  determination. 

Treatment. —  As  Duane  has  well  said,  "There  must  be  no  attempt 
to  treat  an  insufficiency  simply  as  an  insufhcienc}',  but  account  must 
be  taken  of  the  complex  causes  which  lie  at  the  root  of  it." 

Strict  orthophoria  is  rare.  Small  errors  of  the  lateral  muscles  are 
often  unimportant. 

If  there  is  a  constitutional  disorder  or  an  insufficient  nervous  tone, 
this  must  be  treated  on  general  principles.  Strychnin  or  ascending 
doses  of  tincture  of  nux  vomica  have  been  recommended  and  for  the 
purpose  of  improving  the  general  tone  of  the  system  should  be  ad- 
ministered. Galvanism  may  be  tried,  but  it  is  doubtful  if  the  current 
reaches  the  muscle.  Large  doses  of  tincture  of  hyoscj'amus  are  of 
distinct  advantage  in  cases  of  spasmodic  heterophoria. 


614   MOVEMENTS   OF   THE   EYEBALLS   AND   THEIR   ANOMALIES 

In  every  case  of  heterophoria  the  refractive  error  should  be  cor- 
rected according  to  the  rules  already  laid  down.  In  many  instances 
this  alone  will  suffice  to  restore  the  balance  and  cure  the  asthenopia. 
In  esophoria  of  accommodativo  origin  the  total  amount  of  the  hypero- 
pia and  astigmatism  should  be  neutralized  with  suitable  glasses,  which 
are  to  be  worn  constantly,  and  in  high  degrees  of  this  muscle  defect  a 
convex  sphere  of  from  1  to  2  D  may  be  added  to  the  distance  correction 
and  used  in  near  work  in  order  to  diminish  accommodative  overactivity 
(see  also  page  133);  in  exophoria,  especially  with  insufficiency  of  con- 
vergence, the  full  correction  of  the  mj'opia  should  be  ordered  (compare 
with  page  143).  Where  esophoria  exists  with  myopia  and  exophoria 
with  hyperopia,  this  plan  must  be  modified,  and  an  undercorrection  of 
the  refractive  error  prescribed.  Convergence-insufficiency  caused  by 
glasses  of  improper  strength  has  been  described  on  page  611. 

If  the  symptoms  continue,  recourse  should  be  had  to  gymvostic 
exercises  with  prisms.  The  object  is  to  strengthen  abduction  and 
adduction.     A  number  of  methods  are  in  common  use: 

1.  The  patient  is  instructed  to  practise  fusing  the  double  images 
produced  by  viewing  a  candle-flame  situated  6  meters  away.  Abduc- 
tion (prism-divergence)  and  adduction  (prism-convergence)  are  exer- 
cised, beginning  with  the  weakest  prisms  and  gradually  increasing  to 
the  strongest.  This  plan  probabl}^  acts,  as  Maddox  suggests,  by 
training  the  efforts  of  accommodation  and  convergence  to  assume 
broader  relations  to  each  other  in  their  work.  It  is  efFcient  in  selected 
cases. 

2.  Rhythmic  exercises,  contraction  and  relaxation  of  the  muscle 
being  secured  by  causing  the  patient  to  view  a  small  gas-jet  20  feet  dis- 
tant through  adverse  prisms,^  which  are  lowered  and  raised  at  regular 
intervals  of  five  seconds,  beginning  with  weak  and  gradualh'  going  to 
stronger  numbers.  This  is  the  method  of  Dr.  G.  C.  Savage.  This 
author  also  recommends  rhythmic  exercises  by  rotating  convex  cylin- 
ders before  the  eye  for  the  relief  of  cydophoria. 

3.  The  patient  is  provided  with  prisms  double  the  primary  distant 
adduction-power.  The  candle-flame  is  then  slowly  carried,  while  he 
regards  it  fixedly  and  continuously  from  the  near  i)oint  to  the  distant 
point.  This  is  i'ej)eated  until,  without  difficulty,  he  can,  through  the 
prisms,  secvu'c  a  single  image  in  all  parts  of  the  room.  The  strength  of 
the  "handicap-prisms"  should  be  gradually  increased.  For  esoi)horia 
the  reverse  of  the  plan  is  pursued.  This  is  the  method  advocated  by 
Dr.  Gould. 

Referring  to  muscle  exercises,  Duanc  states  (hat  he  regularly  eui- 
ploys  four,  namely:  distant  exercise  with  prisms,  bases  out;  exercise 
with  prisms,  bases  out,  at  near  points;  exercise  with  prisms,  bjiscs  in, 
at  near  points,  and  exercises  in  converging  on  a  pencil-point  (see  also 
I)age  70).     lOxercises  with  prisms,  bases  out,  are  followed  by  most  satis- 

'  "Adverse  prism"  is  a  term  used  l)y  Maddox,  and  means  one  with  il,s  apex  set 
in  the  ojjpositc;  dinH-tion  from  a  "relieving  prism;"  for  example,  ba.se  out  if  the 

inlcriii  nre  ((j  lie  alTeeted,  Im.se  in  if  t.iie  externi  !ue  to  lie  exercised. 


ABNORMAL  BALANCE  OF  OCULAR  MUSCLES,  OR  HETEROPHORIA  615 

factory  results  in  exophoria,  especialh'  in  convergence-insufficiency,  and 
should  always  be  practised  not  only  at  the  distance,  but,  as  Duane  in- 
sists, at  the  near  point.  Exercises  with  prisms,  bases  in,  in  esophoria  at 
the  distant  point,  in  the  author's  experience,  have  not  been  of  any 
value,  but  recent  experience,  based  on  Duane's  advice  to  use  diverging 
prisms  at  near  points  in  cases  of  convergence-excess,  indicates  that  the 
method  may  produce  good  results.  The  author  has  failed  to  observe 
relief  in  hyperphoria  from  prismatic  exercises,  but  Savage's  method  has 
received  the  commendation  of  many  competent  observers,  and  should 
be  tried. 

The  next  method  of  treatment  is  the  'prescription  of  prisms.  The 
action  of  prisms  has  been  explained  (see  page  18).  ^Much  difference  of 
opinion  exists  in  regard  to  their  therapeutic  value.  The  author  be- 
lieves with  Duane  that  ''the  employment  of  prisms  in  lateral  deviations 
is  to  be  avoided  except  as  a  temporarj'  measure,  since  prisms,  base  in, 
tend  to  produce  convergence-insufficiency,  and  prisms,  base  out,  con- 
vergence-excess, so  that  in  both  cases  they  ultimately  increase  the 
deviation  which  they  are  designed  to  correct."  Prisms  may  be  or- 
dered when  the  range  of  movement  is  perfect  but  in  an  unavailable 
position.  The  base  of  the  prism  should  be  placed  toward  the  muscle 
which  is  to  be  aided,  and  the  apex  toward  the  muscle  which  is  to  be 
weakened. 

It  is  usually  uncomfortable  for  the  patient  to  wear  more  than  4°  or 
5°  constantly — i.  e.,  2  or  23>^  over  each  eye.  This  statement,  however, 
admits  of  many  modifications,  and  often  the  strength  of  the  prism  may 
be  increased  much  beyond  this  limit. 

In  permanent  latent  deviations  of  the  vertical  muscles  (right  or 
left  hyperphoria)  the  defect  is  often  quite  small,  and  usualty  not  above 
4°  or  5° ;  hence  prisms  ma}'  readily  be  ordered  for  continuous  use,  and 
combined  with  the  lenses  which  correct  the  refractive  error,  forming  a 
prismosphere.  If,  for  example,  there  is  right  hj^perphoria  of  2°,  a  2° 
prism  base  down  before  the  right  eye  corrects  the  difficulty,  or,  what  is 
equivalent,  the  prism  may  be  divided  between  the  two  eyes — i.  e.,  1° 
base  down  before  the  right,  and  1°  base  up  before  the  left.  It  is  safe 
to  correct  very  trifling  errors  in  the  vertical  muscles  either  with  prisms 
or  by  decentering  the  correcting  lens  to  an  equivalent  degree  (see  page 
20),  providing  these  errors  are  still  maintained  after  continuous  use  of 
glasses  which  neutralize  the  refractive  error. 

In  esophoria,  which  is  a  frequent  cause  of  muscular  asthenopia, 
prisms  are  often  combined  with  the  correcting  lenses  and  worn  con- 
stantly. For  the  reasons  before  stated,  the  author  doubts  the  value  of 
constant  prisms,  with  rare  exceptions,  under  these  conditions. 

In  exophoria  the  constant  use  of  prisms  is  not  advisable.  On  the 
other  hand,  they  msiy  be  a  great  help  in  relieving  the  strain  upon  con- 
vergence by  removing  the  point  of  intersection  of  the  visual  axes  farther 
from  the  eyes,  and  for  this  purpose  they  are  combined  with  reading- 
glasses.  In  high  degrees  of  exophoria,  or  if  there  is  actual  divergence, 
abductive  prisms  are  of  little  use;  if  the  deficiency  of  the  directing 


616    MOVEMENTS    OF    THE    EYEBALLS    AND    THEIR    ANOMALIES 

power  is  determined  to  be  equivalent  to  10°,  one-half  of  this  may  be 
corrected — i.  e.,  2}^°  base  in  over  eadi  eye;  if  it  is  desired  to  remove  all 
effort,  the  faulty  tendency  is  measured  in  the  usual  way,  and  if  it  is 
within  suital)l('  limits,  prisms  are  ordered,  combined  with  the  correcting 
glasses  which  neutralize  the  defect.' 

It  has  also  been  suggested  to  strengthen  the  muscles  i)y  means 
of  orthoptic  exercises — i.  e.,  by  causing  them  to  make  forced  movement 
in  different  directions;  by  making  forced  movements  of  convergence, 
the  patient  being  required  to  look  at  near  objects — "thumb  exercises;" 
by  requiring  the  eyes  to  unite  the  images  of  two  slightly  sei)arated 
objects.     Stereoscopic  exercises  are  also  of  advantage. 

In  the  event  of  failure  to  relieve  asthenopic  symptoms  by  the 
methods  thus  far  described  operative  procedure  may  be  necessary. 
This  consists  of  partial,  complete,  or  graduated  tenotomy  of  the  an- 
tagonistic muscle,  or  of  advancement  of  the  feeble  nuisde  (.see  chapter 
on  Operations).  Whether  advancement  or  tenotomy  should  be  per- 
formed depends  upon  the  conditions.  Advancement  is  indicated  to 
strengthen  a  weak  muscle,  and  tenotomy  if  an  overstroiig  nuiscle 
is  to  be  weakened.  For  example,  in  exophoria  due  to  convergence- 
insufficiency  advancement  of  the  internus  is  a  more  rational  procedure 
than  tenotomy  of  the  externus,  but  if  the  exophoria  depends  upon 
divergence-excess,  tenotomy  of  the  externus  is  the  better  operation. 
The  same  advice  applies  to  csophoria,  convergence-excess  indicating 
tenotomy  of  the  internus,  and  tlivergence-insufficiency  advancement 
of  the  externus.  According  to  circumstances,  one  or  both  externi  or 
interni  may  need  readjustment  or  division.  Operations  on  the  vertical 
muscles  must  be  governed  by  similar  rules.  Surgical  interference  is 
required  only  after  all  other  measures  have  b(H>n  long  and  faitiifully 
tried  and  have  failed  to  give  relief.  While  cases  of  nuiscular  imbalance 
best  treated  bj^  operative  interference,  are  encountered  (aptly  calleil  by 
Risley  "absolute  insufficiencies,"  equivalent  to  the  structural  and 
insertional  anomalies  of  Duaiie),  in  the  opinion  of  the  author  they  rep- 
resent a  limited  proportion  of  the  whole  number.  Moret)ver,  as  our 
knowledge  of  the  etiology  of  abnormalities  of  muscular  balance  in- 
creases and  our  methods  of  non-sni-gical  tr(\*\tmeiit  improve,  this 
numix'i-  grows  steadily  smaller. 

So-called  graduated  tenotomies  and  i)ar(ial  tenotomies  ar(>  per- 
formed by  some  suigeons,  and  it  is  asserted  that  adjustments  are 
exactly  made,  but  in  tiieiii  tlie  author  has  little  faith.  It  is  true  that 
brilliant  I'esults  have  been  made  and  described  by  ex|)erienc(ul  opeia- 
tors,  but  thei'c  is  no  doubt  that  a  good  deal  of  injudicious  "snipping  of 
the  tendons  of  the  ocular  muscles"  has  been  practised. 

Nystagmus.  This  term  is  a|)plie(l  to  ;i  condition  chaiacteri/ed  by 
an  invohnit ar>',  rapid  nioxcuietit   of  the  eyeballs.     The  iiio\'eiueiit  may 

1  When  H  spliciic  Icii.s  i.s  <oiiil>iiii(l  with  n  iirism,  tln'  div  i.itiiin  cfTi'ct  of  tho 
<'()iiit)iii.'iti()n  is  (lilTcn-nt  from  that  ul  the  iirism  .•iloric.  .Mr.  Archili.-ild  I'crcivjil 
(( )|)ht  hiihiiif  Hcvicw,  Oftolx-r,  IS'.ll  l  has  cimst  niclnl  clalMnalc  t:tlilcs  which  nivc 
the  (IcvialiiiK  cITi-cl. 


NYSTAGMUS  617 

be  lateral,  vertical,  rotary,  or  mixed — i.  e.,  a  compound  of  two  varieties. 
According  to  the  character  of  the  movement  there  are  two  chief  types 
of  nystagmus,  namely  the  undulatory  form  (also  called  vihraiory  ny- 
stagmus) in  which  the  movements  have  the  same  to  and  fro  velocity, 
and  the  rhythmic  form  (also  called  resilient  nystagmus)  in  which  a 
comparativel}^  slow  movement  (slow  phase)  in  one  direction  is  followed 
by  a  rapid  return  movement  in  the  opposite  direction. 

The  condition  may  be  congenital  (probably  begins  in  very  early 
life)  or  acquired,  and  is  bilateral  in  the  majority  of  cases,  although  a 
few  instances  of  unilateral  nystagmus  have  been  reported,  with  the 
movements  usually  in  the  vertical  direction.  It  is  possible,  however, 
inasmuch  as  slight  forms  of  nystagmus  are  detected  only  by  using 
the  ophthalmoscope  and  watching  the  fundus,  that  some  of  these  sup- 
posed unilateral  cases  have  actually  been  bilateral. 

Congenital  nystagmus  is  seen  with  cases  of  defective  construction 
of  the  eyeball — coloboma,  microphthalmos,  etc.  It  is  also  common 
in  albinism  and  in  color-blind  persons  with  small  central  scotomas 
(C.  L.  Franklyn).  Nystagmus  occurs  with  opacities  of  the  media, 
especially  when  such  obstruction  to  the  rays  of  light  has  been  caused  by 
diseases  occurring  early  in  life  and  in  blind  eyes  (congenital  cata- 
ract, leucoma  after  ophthalmia  neonatorum) ;  chorioretinitis,  pigmen- 
tary degeneration  of  the  retina,  etc.  In  blind  eyes  the  so-called 
searching  movements  occur;  that  is,  the  eyes  make  a  comparatively  slow 
and  wide  movement  from  the  primary  position,  to  which  after  a  time 
they  again  return,  and  so  the  movements  are  repeated.  Pseudonystag- 
mus,  usually  bilateral,  is  the  term  applied  to  jerky  movements  which 
are  seen  when  one  or  both  eyes  are  rotated  near  to  the  limit  of  their 
excursion  in  one  or  other  direction;  that  is  between  this  point  and  the 
exterior  limit  of  rotation  these  jerky  movements  develop.  It  prob- 
ably depends  upon  fatigue  of  the  muscles.  It  can  be  developed  in 
various  nervous  diseases  especially  Friedreich's  ataxia  and  multiple 
sclerosis. 

Hereditary  nystagmus,  extending  through  a  number  of  generations, 
has  been  especially  studied  by  Nettleship:  two  types  exist,  the  first  is 
male-limited,  the  transmission  being  through  unaffected  females;  in 
the  second  both  sexes  are  affected,  the  descent  being  most  frequent 
through  the  females.     In  this  class  head  movement  is  common. 

Nystagmus  may  be  acquired  in  the  pursuit  of  certain  occupations, 
especially  mining,  and  is  commonly  known  as  ryiiners'  nystagmus. 
It  generally  occurs  among  those  who  use  a  dim  light,  and  whose  work 
necessitates  keeping  the  eyes  in  an  unusual  position  for  many  hours 
together  (Snell).  T.  L.  Llewellyn's  studies  lead  him  to  believe  that  the 
chief  cause  of  this  form  of  nystagmus  is  strain  caused  by  deficient  light. 
Errors  of  refraction  increase  the  liability  to  nystagmus.  Miners' 
nystagmus  has  also  been  attributed  to  muscle  fatigue  and  to  insuf- 
ficiency of  the  fusion  power  (Dransart  and  Van  Houtte).  The  visual 
fields,  according  to  Cridland,  are  similar  to  those  observed  in  traumatic 
neurasthenia. 


618    MOVEMENTS   OF   THE    EYEBALL    AND    THEIR    ANOMALIES 

Nystagmus  is  common  in  diseases  of  the  nervous  system,  particU' 
larly  disseminated  sclerosis  and  Friedreich's  ataxia  as  previously 
noted,  but  a  true  nystagmus  also  occurs  in  tiiese  affections.  Nystag- 
mus is  associated  with  many  diseases  of  the  brain,  and  has  been  noted 
with  great  frequency  in  tumors  of  the  cerebellum.  Head-jerkings  and 
nystagmus  maj'  occur  in  young  children,  constituting  the  so-called 
spasjnus  nutans.  It  may  be  unilateral.  Voluntary  nydagmus  has  been 
reported  and  a  rare  variety  is  the  so-called  latent  nystagmus,  which  can 
be  developed  only  by  excluding  one  eye  from  binocular  vision  (From- 
aget,  Van  der  Hoeve).  The  subjects  of  nystagmus  may  be  greatly  dis- 
turbed, ]:)ut  not  in  all  its  varieties,  by  the  apparent  movement  of  objects, 
by  difficulty  in  reading  and  by  vertigo;  poor  vision  is  common;  photo- 
phobia may  be  present. 

Nystagmus  has  been  ascribed  to  chronic  fatigue  of  the  muscles  and 
oscillation  of  the  globe  consequent  upon  the  muscular  atonj',  and  also 
to  a  central  origin.  Duane  believes  that  true  nystagmus  depends  upon 
a  perversion  of  the  centers  for  parallel  and  parallel-rotatory  movements 
and  not  on  peripheral  muscle  or  nerve  lesions. 

Vestibular  nystagmus,  produced  by  irritation  of  the  labyrinth,  may 
be  horizontal,  vertical,  and  rotary,  and  the  movement  consists  of  a 
slow  followed  by  a  rapid  oscillation,  most  intense  when  the  visual  axes 
are  turned  in  the  direction  of  the  rapid  movement,  diminished  when 
turned  in  the  opposite  direction.  This  type  of  nj'stagmus,  an  interpre- 
tation of  vestibular  disturbance,  can  be  readily  induced  by  Bdrdny's 
caloric  test  (syringing  the  ear  with  hot  or  cold  water),  by  the  rotation 
test  (the  rotations  being  made  with  the  aid  of  Bdrdny's  chair  or  one  of 
its  modifications),  or  by  galvanic  stimulation.  These  tests  have  as- 
sumed great  importance  from  the  otoneurologic  standpoint  and  are  of 
unusual  value  in  examining  candidates  for  service  in  the  aviation 
corps;  the}'  have  added  an  important  chapter  on  the  localization  of 
intracranial  lesions.^ 

Treatment. — If  practicable,  in  cases  of  nystagmus  where  there  is 
interference  with  the  reception  of  perfect  retinal  images,  the  best  pos- 
sih)le  vision  should  be  restored  by  correction  of  refractive  error,  by 
tenotomy,  or  by  iridectomy  for  new  pupil,  according  to  the  indications. 
Very  often  good  results  have  been  noted.  If  nj-stagnuis  is  l)rought 
about  by  any  occupation,  the  evident  indication  is  to  remove  the 
patient  from  his  surroundings.  For  central  nystagmus  from  brain  or 
cord  disease  there  is  practically  no  rcnicdy.  In  some  instances  of 
ac(juiretl  nN'stagnius  benefit  has  been  reported  fntm  the  local  use  of 
eserin  and  the  internal  administration  of  strychnin. 

Monocular  Diplopia. — This  character  of  diplopia  has  been  ex- 
plained by  one  of  sevcial  conditions:  (1)  By  anomalies  of  refraction, 
particularly  astigmatism;  (2)  l)y  opacities  in  the  cornea  or  lens  or  by 
anoniulics  of  the  pupil,  for  example,  polycoria  (see  also  page  430);  (3) 

'  I""or  a  full  coM.sidcnition  of  iiy.stiinniu.s  in  tlicso  rrlntioiisliijjs  consult  "K(|uili- 
briuiii  and  Vertigo"  !>>■  Isaac  II.  Jones  and  its  chai)tcr  containing  an^annlysis  of 
patholoK>c  ciujt'H  by  Lewis  Fisher. 


MONOCULAR      DIPLOPIA  619 

by  irregular  cramp  of  the  ciliary  muscle;  (4)  by  complete  or  partial 
constriction  of  the  eyelids,  by  which  they  are  made  to  impinge  on  the 
cornea  (G.  J.  Bull);  (5)  by  hysteria  or  allied  functional  nervous  dis- 
turbance; (6)  by  organic  disease  of  the  brain  or  its  membranes,  as- 
sociated with  abducens  paralysis  (Gunn  and  Anderson);  (7)  by  simula- 
tion, the  symptom  being  an  invention  of  the  patient  for  the  purpose  of 
magnifying  the  result  of  injuries. 


CHAPTER   XX 
DISEASES  OF  THE  LACRIMAL  APPARATUS 

Diseases  of  the  lacrimal  structure  naturally  divide  themselves 
into  those  which  have  their  seat  in  the  lacrimal  fj;lands  and  those  which 
affect  the  drainage  sj^stem — i.  e.,  the  puncta,  canaliculi,  lacrimal  sac, 
and  nasal  duct. 

Dacryo=adenitis. — This  is  an  inflammation  of  the  lacrimal  gland, 
a  comparatively  rare  affection,  which  may  be  acute  or  chronic,  suppura- 
tive or  7ion-suppurative. 

Non-suppurative  dacryo-adenitis,  on  account  of  its  analogy  to 
bilateral  parotitis,  has  been  called  mumps  of  the  lacrimal  gland  (Hirsch- 
berg).  It  may  be  caused  by  influenza,  small-pox,  measles,  scarlet 
fever,  leukemia,  and  mumps.  Tuberculous  dacryo-adenitis  is  rare,  ac- 
cording to  Stieren,  who  reports  an  example  of  this  affection,  only  12 
cases  being  on  record.  The  unilateral  chronic  form  of  inflammation  of 
the  laciimal  gland  is  more  common,  and  has  been  observed  in  scrofu- 
lous subjects,  and  ma}'  be  caused  by  an  injury  or  follow  disea.>^es  of  the 
conjunctiva  and  cornea. 

If  the  gland  is  chronically  (enlarged,  palpation  will  reveal  its  lobu- 
lated  border;  if  the  inflannnation  is  acute,  there  are  pain,  t(>nderness, 
and  swelling  at  the  upper  and  outer  part  of  the  eyelid,  with  chemosis  of 
the  conjunctiva;  the  rotation  of  the  eye  upward  and  outward  may  be 
limited.  This  may  go  on  to  suppuration,  and  the  abscess  usually 
points  upon  the  skin,  but  also  through  the  conjunctiva;  strej^tococci, 
stai)h3d()Cocci  and  pneumococci  are  found  in  the  i)urul"nt  material. 
Acute  dacryo-adenitis  may  result  from  infections  from  the  conjunctiva, 
from  infectious  diseases,  and  from  injury.  Metastatic  dacryo-adenitis 
in  the  subjects  of  gonorrhea  has  been  described. 

Treatment. — Pads  of  gauze  steeped  in  hot  boric  acid  lotion  or  a 
40  per  cent,  solution  of  suli)hate  of  magnesia  may  i)e  applied  to  r(>lieve 
pain,  and  at  the  first  appearance  of  pus  an  incision  should  be  made 
either  through  the  integument  parallel  to  the  evei)row,  or  through  the 
conjunctiva.  If  induration  of  the  gland  occuis,  tiiis  should  be  treated 
locally  with  iodiii  or  iodid  of  cadniiiini  oint  iiiciil .  A  I  ulx-iculous  gland 
should  1)('  i('iiio\'('(l. 

H\pertrophy  of  the  lacrimal  jjlaiul  has  Ixcn  ob.served  at  birth, 
l)Ut  usually  is  seen  in  later  >  i  ais,  and  consists  in  an  induratetl  lobulated 
tumoi'  having  its  situation    in  the  up|)(  r  ami  oulci-  pari  of  the  orbit. 

Atrophy  of  the  lacrimal  ^land,  as  the  irsull  of  xerophilialiuos. 
has  been  (iociibcd. 

Spontaneous  prolapse  of  the  lacrimal  Kland  appears  in  the 
form  of  a  soft   movable  tumor  under  llir  upprr  eyelid.      I  lypcit  ro|)hy 

tijd 


TUMORS    OF    THE    LACRIMAL    GLAND 


621 


and  prolapse  or  prominence  of  the  palpebral  portion  of  the  lacrimal 
gland  may  occur  in  various  corneal  and  conjunctival  inflammations, 
and  is  evident  on  everting  the  upper  lid. 

The  treatment  consists  of  extirpation  of  the  prolapsed  organ. 

Traumatic  Dislocation  of  the  Lacrimal  Gland. — This  is  a  rare 
accident,  and  occurs  most  frequently  in  young  children  (Villard),  but 
also  in  adults  (E.  Jackson).  Usually  the  gland  prolapses  through  a 
wound  in  the  upper  lid.  If  the  gland  can  be  returned  to  its  place  and 
the  wound  sutured,  this  procedure  is  preferable  to  excision,  which, 
however,  may  be  necessary,  especially  if  infection  occurs. 

Fistula  of  the  Lacrimal  Gland. — This  may  remain  on  account 
of  the  rupture  of  an  abscess,  but  has  also  been  recorded  as  a  congenital 
defect  at  the  outer  third  of  the  upper  lid.  A  fringe  of  hair  may  sur- 
round the  opening  of  the  fistula. 

The  fistula  may  be  closed  by  repeated  cauterization  or  by  a  plastic 
operation;  in  the  event  of  the  fail- 
ure of  these  measures,  extirpation 
of  the  gland  is  indicated. 

Syphilis  of  the  Lacrimal 
Gland. — The  lacrimal  gland  is 
singularly  free  from  syphilitic  affec- 
tions, but  specific  induration  and 
inflammation  have  been  described, 
that  is  syphilitic  dacryo-adenitis,  in 
most  instances  (and  there  are  only 
a  few"  on  record)  a  gummatous 
process.  A  swelling  (inflammation) 
of  the  lacrimal  gland  in  association 
with  a  chancre  of  the  upper  retro- 
tarsal  fold  has  been  observed  (de 
Lapersonne).  The  usual  antisyph- 
ilitic  treatment  is  required. 

Dacryops. — This  affection, 
often  classified  with  diseases  of  the 

conjunctiva,  is  caused  by  a  cj'stic  distention  of  one  of  the  main  gland- 
ducts  or  of  one  of  those  of  the  accessory  lacrimal  gland,  and  appears 
in  the  form  of  a  bluish,  translucent  swelling  beneath  the  conjunct!  a 
at  its  upper  and  outer  part.  If  the  mouth  of  the  excretory  duct  is  not 
occluded,  pressure  upon  the  tumor  causes  a  few  drops  of  liquid  to  es- 
cape. It  is  a  comparatively  infrequent  affection,  about  35  cases  being 
on  record  (Ernest  Thomson). 

Tumors  of  the  Lacrimal  Gland. — Adenoma,  fibroma,  myxoma, 
adeno-angioma,  epithelioma,  carcinoma,  osteochondroma,  l3aTiphoma, 
cylindroma,  and  sarcoma  occur.  Tubercle,  in  the  form  of  a  small  al- 
mond-shaped tumor,  has  also  been  reported  in  this  region  either  in 
association  with  systemic  tuberculosis  or  as  an  isolated  lesion.  Cysts 
and  concretions  (dacryoliths)  occur.  The  concretions  are  contained  in 
the  excretory  ducts,  and  are  composed  of  concentric,  chalky  masses 


Fig.  258. — Enlargement  and  prolapse 
of  the  palpebral  portion  of  the  lacrimal 
gland  in  ah  eye  with  kerato-iritis. 


622        DISEASES  OF  THE  LACRIMAL  APPARATUS 

(Levi).  According  to  Warthin,  the  majority  of  lacrimal  tumors  are, 
most  probably,  mixed  tumors  of  endothelial  origin,  similar  to  those  of 
the  parotifl  and  sul)niaxillary  glands.  They  tend  to  form  cartilaginous, 
hyaline,  and  myxomatous  tissue,  and  their  malignancy  is  relatively 
slight.  F.  H.  Verhoeff  believes,  however,  that  mixed  tumors  of  the 
lacrimal  gland  are  essentially  epiblastic  in  origin,  that  they  are  dan- 
gerous to  sight  and  to  life,  and  that  thej'^  should  be  extirpated  as  soon 
as  possible. 

To  a  symmetric  enlargement  of  the  lacrimal,  the  parotid  and  sali- 
vary glands  the  name  Mikulicz's  disease  is  applied.  It  is  unassociated 
with  anj'  systemic  affection.  According  to  S.  Lewis  Ziegler,  the  tume- 
factions should  be  regarded  as  true  lymphomas.  The  affection  has  also 
been  ascribed  to  tuberculosis. 

Anomalies  of  the  Puncta  Lachrymalia  and  Canaliculi. — 1. 
Congenital  Anomalies. — Double  puncta  lachrymalia  and  canaliculi 
have  been  observed  as  congenital  anomalies,  and  Majewski  has  ob- 
served quadruple  puncta.  There  may  l)e  congenital  absence  of  these 
structures,  or  the  lacrimal  points  maj'  be  wanting  and  the  canals  may 
be  represented  by  furrows  along  the  edge  of  the  lid. 

2.  Acquired  Anomalies. — The  slightest  change  in  the  natural  rela- 
tion of  the  lower  punctum  to  the  eye,  against  which  it  is  directed  back- 
ward, causes  epiphora,  or  an  overflow  of  tears. 

The  most  fruitful  sources  of  such  abnormal  relationship  are  the 
various  chronic  inflammations  of  the  lid  and  conjunctiva — blepharitis, 
trachoma,  and  ectropion — and  facial  palsy  and  wounds  of  this  region. 
In  facial  pals.y,  watering  of  the  eye  is  sometimes  an  early  .symptom, 
and  is  caused  partlj^  by  the  loss  of  the  compressing  power  of  the  lid, 
especially  in  the  fibers  of  Horner's  muscle,  and  partly  bj-  the  falling 
away  of  the  punctum.  An  overflow  of  tears  may  follow  an  abnormal 
position  or  enlargement  of  the  caruncle.  All  these  conditions  cause  a 
malposition  of  the  punctum  laclirymale. 

Epiphora  is  also  caused  by  a  stye  or  tumor  of  the  lid  near  the  punc- 
tum, or,  if  the  canaliculus  is  closed,  by  the  presence  of  a  foreign  body, 
usually  a  cilium;  by  a  mass  of  fungus  (streptothrix) ,  which,  by  becoming 
calcified,  may  form  a  so-called  tcar-stonc,  dacryulitli,  and  bj-  a  pohjp. 
In  like  manner  chronic;  conjunctivitis  and  marginal  blepharitis  may  close 
either  the  lacrimal  point  or  the  canaliculus.  These  affections  are 
included  under  the  terms  stenosis  of  the  punctum  lachrytnale  and 
obstruction  of  the  canaliculus  (for  additional  causes  of  epiphora,  see 
pages  ()-12,  ()17). 

Treatment.  II  a  lorcigii  body  is  prc^scnt,  it  is  usuall\'  necessary  to 
slit  the  canaliculus  in  order  to  remove  it. 

In  many  ca.ses  of  epiphora  which  depend  simply  ui)on  closure  of 
the  iiiciinial  point  this  may  be  opened  by  means  of  a  gold  or  silv(T 
pit)  or  a  dilator,  which  is  pushed  ;doiig  llie  caiiahculus.  Afl(>rward  the 
permeability  of  tiie  lacrimal  duct  may  l)e  tested  by  inserting  the  point 
of  an  Anel  syringe  and  inj(>cting  boric  acid  solution  and  observing 
whether  it  p;isses  freely  into  tlu^  nose.      This  very  simple  proccnlure  will 


ANOMALIES   OF   THE    Li^CRTMAL   SAC   AND   NASAL   DUCT      623 

often  afford  great  relief  without  the  necessity  of  either  shtting  the 
canahculus  or  dilating  the  duct.  If  the  epiphora  has  been  caused 
by  facial  pals}^,  the  treatment  advised  does  not  apply. 

Anomalies  of  the  Lacrimal  Sac  and  Nasal  Duct. — 1.  Dacryo- 
cystitis.— The  symptom  in  affections  of  the  lacrimal  sac  and  nasal 
duct  which  is  always  present  is  epiphora;  the  eye  swims  in  tears,  and 
these  are  excited  to  overflow  by  exposure  to  dust,  cold,  or  wind;  the 
caruncle  and  plica  are  swollen;  the  neighboring  conjunctiva  is  hypere- 
mic  and  injected  (lacrimal  conjunctivitis);  the  skin  is  macerated,  and 
the  margins  of  the  lid,  especially  toward  the  nose,  show  signs  of 
blepharitis. 

Usually  there  is  slight  distention  over  the  region  of  the  lacrimal  sac 
[mucocele,  lacrimal  tumor),  and  pressure  upon  this  expresses  through 
the  puncta  the  retained  fluid,  which  is  a  clear  or  semitransparent  viscid 
mucus  {dacryocystitis  catarrhalis) ,  or  turbid  from  mixture  with  purulent 
material  {dacryocystitis  hlennorrhoica) . 

This  chronic  distention  of  the  lacrimal  sac  is  liable  to  develop  into  a 
suppurative  inflammation  producing  acute  dacryocystitis,  which  may  be 
preceded  by  fever  and  chill;  the  lids  and  region  of  the  nose  become 
tense  and  tender  to  the  touch,  and  a  red  and  brawny  swelling  resem- 
bling erysipelas,  for  which  it  not  infrequently  has  been  mistaken,  over- 
spreads the  region. 

Should  a  phlegmonous  inflammation  involve  the  cellular  tissue 
{dacryocystitis  phlegmonosa)  which 
surrounds  it,  the  pus  burrows  in  ■ 
front  of  the  sac,  forms  pouches  in 
the  connective  tissue,  and  in  most 
instances  the  lacrimal  abscess  thus 
formed  points  below  the  te7}do  oculi. 
If  unmolested,  the  abscess  ruptures 
externall}^  with  the  formation  of  a 
fistulous  opening  into  the  sac,  the 
mouth  of  which  is  surrounded  bj- 
pouting  granulations  (Fig.  259). 
Associated  with  dacryocystitis  and       ^^     „.„     t^ui  j 

.     .  .  oil         •  Fig.  2o9. — rhlegmonous  dacryocystitis; 

CaUSmg  it  IS  stricture  of  the  lacrimal  pouting  granulations  surround  the  fistu- 
duct.  lous  orifice   (from  a  patient  in  the  Chil- 

2*.  Prelacrimal  Sac  Abscess.—  Wren's  Hospital). 
This  consists  of  a  swelhng  above  the  internal  palpebral  ligament  and  a 
little  external  to  the  region  of  the  lacrimal  sac,  associated  with  a 
fistulous  opening,  from  which  pus  flows,  having  no  connection  with  the 
sac  itself.  It  may  be  caused  by  a  blow  at  the  inner  angle  of  the  eye 
and  may  be  associated  with  caries  and  perforation  of  the  lacrimal 
bone  (Bull).  The  same  condition  appears  without  injury  in  children 
who  are  the  subjects  of  hereditary  syphilis. 

The  condition  is  to  be  distinguished  from  a  true  lacrimal  abscess  by 
the  fact  that  there  is  no  interference  with  the  passage  of  tears  from  the 
conjunctiva  into  the  sac,  and  by  the  absence  of  acute  inflammation. 


L 


624  DISEASES    OF    THE     LACRIMAL    APPARATUS 

Prelacrimol  sac  cysts  are  described,  and  small  tumors  may  appear  in  this 
region.  One  removed  and  examined  l)y  the  autlior  had  all  tlieliistologic 
appearances  of  tubercle. 

The  treatment  is  that  of  an  abscess,  together  with  such  constitu- 
tional measures  as  may  be  indicated  by  the  dyscrasia  of  which  the 
patient  is  the  subject. 

3.  Fistula  of  the  Lacrimal  Sac.-This  occasionally  has  been  ol)- 
served  as  a  congenital  anonial}',  and  may  be  present  on  only  one  side  or 
on  both  sides.  The  opening  is  usually  directly  under  the  internal 
palpebral  ligament. 

Generally  a  fistulous  opening  into  the  sac  is  caused  by  the  rupture 
of  a  lacrimal  abscess,  but  it  may  result  from  a  carious  condition  of  the 
upper  canine  teeth.  The  opening  may  appear  about  1  cm.  below  the 
punctum,  but  also  in  various  spots  along  a  line  which  runs  outward, 
parallel  to  the  lower  orbital  border. 

It  usually  comnuinicates  with  the  sac,  but  in  rare  instances  the 
opening  may  lead  into  the  lower  canal  only,  the  sac  above  being 
shrunken.  Pus  and  mucopus,  and  later  tears,  which  should  descend 
into  the  duct,  exude  from  the  opening,  which  for  a  long  time  persists 
as  a  fine  orifice,  at  the  mouth  of  which  appears  a  drop  of  clear  fluid. 
This  is  the  so-called  capillary  fistula. 

The  condition  is  to  be  difTerentiated  from  a  buccal  fistula  below  the 
margin  of  the  orbit,  by  observing  that  in  the  latter  the  situation  is 
never  accurately  at  the  orbital  margin,  that  a  sound  never  passes  up- 
ward, but  only  downward,  laterally,  or  posteriorly,  and  that  the  secre- 
tion is  always  purulent.  Von  Szily  with  the  aid  of  x-ray  examination 
has  discovered  that  there  maj'^  be  a  communication  of  the  tear  sac  with 
the  nose,  that  is  an  internal  fistula  of  the  lacrimal  sac:  in  other  words 
a  spontaneous,  false  passage.  Such  a  condition  may  be  associated  with 
empyema  of  the  ethmoid  cells. 

4.  Obstruction  of  the  Nasal  Duct. — This  always  antedates  the 
affection  of  the  sac.  It  may  l)e  situated  at  any  part,  but  selects  by 
preference  the  point  at  which  the  nasal  duct  enters  into  the  sac.  or  the 
lower  end  where  it  passes  into  the  nasal  chambei-. 

In  the  early  stages  of  catarrhal  dacryocystitis  there  probably  is  no 
true  stricture  of  the  duct,  but  th(>  flow  from  the  sac  into  the  nose  is 
prevented  by  swelling  of  the  mucous  tissue:  later,  and  in  other  in- 
stances, cicat  ficial  sti'ictiires  occui-. 

Causes  of  Disease  of  the  Lacrimal  Sac  and  Nasal  Duct. — Disea.'^e 
of  the  lacrimal  sac  is  rarely  primary.  In  young  infants  so-called 
dacryocystitis  is  not  iiifreciuently  s(>en — lacrimal  hlrnnarrlua  or  atresia 
of  the  newborn.  Dmialil  (liinn  thinks  tliat  the  eause  of  nnicocele  of 
newl)oiii  children,  becoming  .allerward  dacryocyst  it  is,  depends  upon  a 
dilated  duct,  the  dilatation  being  l)rought  about  during  fetal  life  by 
ob.struction  at  the  lower  end,  depending,  for  example,  upon  .^ome  de- 
velopmental fault.  The  pus  usu.ally  contains  pneumococci;  staphy- 
lococci, streptococci,  and  H.acleiiuni  coh  are  .also  occasionally  |)rc.sent. 
M.any    cases    depend    upon    rcteiitidn    of    sep;ir:iled    cells    because    of 


ANOMALIES    OF    THE    LACRIMAL    SAC    AND    NASAL    DUCT      625 

imperforation  of  the  septum  between  the  lacrimonasal  duct  and  the 
nasal  chamber  (Zentmayer).  In  these  infants  pressure  over  the  sac 
causes  the  contained  secretion  to  escape  into  the  conjunctival  sac 
through  the  punctum;  sometimes  both  sacs  are  involved;  primarily 
the  evidences  of  acute  inflammation  are  lacking. 

Both  a  local  and  a  general  disposition  to  tear-duct  troubles  has 
been  assumed  by  some  authors,  and  by  others,  for  example,  Haab, 
hereditary  predisposition  has  been  given  etiologic  prominence.  The 
female  sex  suffers  more  frequently  than  the  male,  and  the  left  tear- 
duct  is  more  often  diseased  than  the  right  (Cahn). 

In  the  majority  of  cases  blennorrhea  of  the  sac  is  caused  by  a  reten- 
tion of  the  secretion  on  account  of  stricture  or  obstruction  in  the  nasal 
duct,  and  the  participation  of  the  lining  of  the  sac  in  an  inflammation  of 
the  nasopharynx.  In  other  instances  strictures  result  from,  rather  than 
cause,  the  blennorrhea.  A  proper  appreciation  of  the  pathologic  con- 
ditions of  the  nasal  mucous  membrane  in  relation  to  diseases  of  the 
lacrimal  apparatus  is  of  the  utmost  importance,  and  in  nearl}^  every 
case  of  disease  of  the  lacrimal  sac  and  of  the  lacrimonasal  duct  morbid 
conditions  of  the  nasal  chambers  and  of  the  nasopharynx  are  present, 
especially  tumefaction  of  the  mucous  membrane,  hypertrophy,  and 
abnormal  position  of  the  turbinate  bones,  strictures  after  nasal  ulcers, 
and  caries  of  the  nasal  bones.  Of  great  importance  in  this  regard, 
especially  in  suppurative  dacryocystitis,  is  infection  of  the  ethmoid 
cells  and  of  the  antrum  of  Highmore,  and  in  a  search  for  a  primary  cause 
these  regions  deserve  accurate  investigation.  In  not  a  few  instances 
suppuration  in  the  lacrimal  portion  of  the  ethmoidal  cells  has  been 
mistaken  for  dacrj'ocystitis. 

Although  it  might  seem  natural  that  conjunctivitis,  and  especially 
purulent  conjunctivitis,  should  cause  lacrimal  disease,  this  is  by  no 
means  frequently  the  case.  Conjunctivitis  and  blepharitis,  so  often 
accompanying  disorders,  follow  rather  than  cause  the  lacrimal  affection. 

Obstruction  of  the  duct  and  disease  of  the  sac  are  sequels  of  measles, 
scarlet  fever,  and  especially  small-pox,  because  these  exanthems  are 
accompanied  by  inflammation  of  the  nasal  mucous  membrane. 

Periostitis  and  caries  of  the  lacrimal  bone,  the  result  of  syphilis, 
are  important  causes.  Gummatous  growths  may  block  the  sac  and  go 
on  to  rapid  suppuration.  Igersheimer  calls  especial  attention  to  the 
frequency  with  which  hereditary  lues  is  a  cause  of  disease  of  the  lacrimal 
passages  in  children.  Tuberculosis  of  the  lacrimal  sac  is  of  not  infre- 
quent occurrence.  Trachoma  and  dacryocj'stitis  are  frequently  in 
association  and  trachoma  of  the  lacrimal  sac  is  well  known;  in  such 
circumstances  it  becomes  friable  and  difficult  to  excise  (Butler) . 

The  relation  between  asymmetry  of  the  face  and  disease  of  the 
lacrimonasal  duct  deserves  mention;  indeed,  Hasner  assumed  that  a 
local  disposition  to  these  disorders  depended  upon  this  asymmetry. 
Traumatism  accounts  for  certain  cases.  Most  impermeable  obstruc- 
tions follow  injuries  and  the  rough  use  of  bougies.  Stoppage  of  the 
lacrimonasal  duct  may  be  caused  by  pressure  from  neighboring  tumors 

40 


626  DISEASES    OF    THE    LACRIMAL    APPARATUS 

— for  example,  in  the  antrum  of  Highmore,  and  by  foreign  bodies  lodged 
in  the  lower  lacrimal  canal  and  in  the  nasal  chambers.  Actinomycosis 
of  this  region  has  been  reported  (von  Schroeder). 

Fistulas,  especialh'  those  seen  in  infants,  often  arise  from  disease 
of  the  bone,  which,  in  turn,  is  the  result  of  inherited  syphilis. 

Tumors  of  the  lacrimal  sac  are  uncommon;  epithelioma  (Pasetti), 
sarcoma  (T.  H.  Butler),  and  plasmoma  (Verhoeff  and  Derby)  have 
been  observed. 

Prognosis  in  Lacrimal  Disease. — The  well-known  fact  that  under 
tlie  most  skilful  treatment  affections  of  the  tear-passages  often  stub- 
bornly resist  treatment  renders  a  guarded  prognosis  necessary.  This 
depends  entirely  upon  the  condition  of  the  nasal  chambers,  the  dura- 
tion of  the  malady,  the  permeability  of  the  stricture,  and  the  cause  of 
the  trouble.  If  the  latter  is  the  result  of  injury  the  j)rognosis  becomes 
especially  grave,  and  the  malady  may  be  irremediable.  In  recent  j'ears 
scientific  methods  of  treatment  have  greatly  improved  prognosis, 
particularly  because  the  effects  of  useless  and  sometimes  reckless  in- 
troduction of  probes  are  not    so  frequenth'  in  evidence. 

Character  of  the  Lacrimal  Secretion  under  Pathologic  Con- 
ditions.— The  lacrimal  sac  is  a  reservoir  for  the  fluid  secreted  by  the 
conjunctiva,  and  this  fluid  is  more  or  less  loaded  with  micro-organisms. 
The  streptococcus  pj'Ogenes,  pneumococcus,  and  other  pathogenic 
organisms  are  always  present  in  dacryocj'stitis.  If  the  cornea  is  ab- 
raded, or  if  a  solution  of  continuity  in  this  membrane  is  necessitated 
by  an  operation,  the  presence  of  these  organisms  in  the  fluid  becomes  a 
serious  complication.  They  maj^  turn  a  simple  abrasion  into  a  slough- 
ing ulcer  or  an  aggravated  hypopyon-keratitis  (page  265).  They 
may  prevent  the  healing  of  an  ordinary  keratitis,  and  finally  they  may 
inoculate  an  operative  wound  and  defeat  the  object  of  the  operation. 
For  this  reason  it  is  most  important  that  in  any  of  the  three  conditions 
just  quoted  the  permeability  of  the  nasal  duct  should  be  ascertained. 
If  it  is  strictured,  it  should  be  opened,  and  the  walls  of  the  lacrimal  sac, 
if  inflamed,  brought  to  a  healthy  condition  as  speedily  as  possible,  or 
the  sac  should  be  extirpated.  The  importance  of  this  relation  of  the 
lacrimal  apparatus  to  diseases  of  the  cornea  and  to  the  prognosis  of 
cataract  operations  has  been  elsewhere  described. 

Treatment  of  Diseases  of  the  Lacrimal  Sac  and  Duct.  ( dnscrva- 
tive  measures  .should  always  be  tried  lirst  viz..  intranasal  licatment, 
massage  over  the  sac  while  the  inner  canthus  is  kept  filled  witli  an  anti- 
septic liquid,  and  dilatation  of  the  puiiclmu  and  irrigation  of  the  sac. 
Many  cases  of  simple  ej)iphora  are  due  to  anu'ti<>i)ia  and  lu'tcrophoria 
and  even  to  various  nervous  diseases — for  example,  tabes  ilorsalis  and 
neurasthenia — hence  operative  interference  is  to  lie  deprecated  unless 
the  exact  cause  of  the  condition  is  tiseertained.  l^piphora  may  be  an 
early  sign  of  exophthalmic  goiter  (Berger,  J.  T.  C'arpentei). 

In  oiganit^  cases,  usually,  tlu^  i"ollowing  procedures  are  recom- 
mended: slitting  the  canaliculus,  introducing  a  probe  into  the  nasal 
<luct,  and  syringing  the  sac  and  nnsolacriniMl  duct;  »)r,  in  the  presence 


TREATMENT  OF  DISEASES  OF  THE    LACRIMAL    SAC  627 

of  proper  indications,  excision  of  the  lacrimal  sac  or  intranasal  drainage 
(page  759).  The  method  of  slitting  the  canaliculus  and  the  introduc- 
tion of  a  probe  are  described  on  page  757. 

After  the  canaliculus  has  been  dilated  or  incised,  the  duct  and  the 
sac  should  be  washed  out  thoroughly  with  some  antiseptic  fluid — a 
saturated  solution  of  boric  acid  or  a  1  :  5000  solution  of  bichlorid  of 
mercury,  or  formaldehyd  1  :  3000  or  physiologic  salt  solution.  Great 
care  should  be  employed  in  using  solutions  of  argyrol  and  protargol,  lest 
they  escape  into  the  surrounding  structures  and  produce  unsightly 
staining  of  the  skin.  They  should  not  be  injected  into  the  sac. 
Mercurophen  (1-8000)  and  mercurochrome  (one  per  cent.)  are 
valuable. 

Some  surgeons,  as  a  rule,  split  the  upper  canaliculus,  although  the 
usual  practice  is  to  approach  by  means  of  the  lower  passage.  If  there 
is  much  distention  of  the  sac,  it  has  been  suggested  to  enter  the  upper 
passage  and  incise  both  this  and  the  wall  of  the  sac. 

In  making  use  of  probes,  it  is  advisable  to  begin  the  first  trial  with  a 
No.  1  conical  probe  (Bowman's  or  Williams');  if  this  fails,  a  smaller 
one  may  be  tried.  Either  rapid  or  gradual  dilatation  is  employed,  the 
latter  being  the  preferable  method.  Undue  efforts  should  never  be 
used,  as  it  is  extremely  easy  to  make  a  false  passage  and  perforate  the 
delicate  structure  of  the  lacrimal  bone,  while  roughness  in  the  use  of 
probes,  by  scraping  off  the  mucous  membrane,  may  cause  the  most  im- 
permeable type  of  stricture. 

Often  it  is  not  necessary  to  use  probes  at  all.  The  point  of  an 
Anel  syringe  charged  with  a  physiologic  salt  solution  or  an  antiseptic 
lotion  may  be  readily  introduced  through  the  punctum  into  the  canalic- 
ulus until  it  reaches  the  entrance  into  the  sac  which  is  thus  thoroughly 
washed  out.  Should  the  fluid  pass  out  through  the  nose  it  is  evident 
no  material  obstruction  exists  in  the  lacrimonasal  duct.  This  maneu- 
ver is  materially  assisted  if  a  drop  of  adrenalin  solution  (1-1000)  is 
instilled  with  the  cocain  prior  to  the  operation. 

Sounds  should  be  used  at  first  every  second  or  third  day,  but  as  the 
case  progresses  longer  intervals  msiy  elapse.  Large  probes  (4  mm.  in 
diameter)  are  advocated  by  Theobald,  but,  in  the  author's  experience, 
are  not  essential.  Ziegler,  using  a  dilator  which  he  has  designed, 
rapidly  dilates  the  duct  not  only  in  cases  of  obstruction  but  when  it  is 
desired  to  increase  drainage  from  the  conjunctival  sac. 

If  a  lacrimal  abscess  supervenes  and  is  seen  early,  the  canaliculus 
should  at  once  be  slit  and,  if  possible,  the  secretion  evacuated  and 
the  passage  into  the  nose  restored.  Frequently  the  pain  and  swelling 
are  such  as  to  render  this  impossible,  and  the  opening  must  be  made 
upon  the  face,  about  1  cm.  below  the  palpebral  tendon,  cutting  down- 
ward and  outward.  The  cavity  should  then  be  thoroughly  cureted, 
packed  with  gauze,  and  allowed  to  heal  gradually  from  the  bottom. 

An  excellent  practice  is  to  use  hot  compresses  over  the  swelling, 
preferably  of  carbolized  water,  at  a  temperature  of  120°  F.,  frequently 
changed  and  applied  for  five  or  ten  minutes  at  a  time.     Later  the  pas- 


628        DISEASES  OF  THE  LACRIMAL  APPARATUS 

sage  into  the  nose  may  be  rendered  patulous  with  probes,  in  the  manner 
already  described.  The  practice  of  introducing  a  lead  or  silver  style 
the  author  has  abandoned,  although  many  surgeons  are  strongly  in 
favor  of  its  use,  especially  the  use  of  a  lead  stylo,  wiiich  is  preferable 
to  a  canula  (H.  Moulton).  The  passage  of  bougies  of  gelatin  impreg- 
nated with  30  to  50  per  cent,  of  protargol  has  been  recommended 
(Antonelli). 

Tlie  treatment  of  dacryocystitis  of  infants  should  consist  in  the  use 
of  a  simple  collyrium,  boric  acid  or  boric  acid  and  sulphate  of  zinc,  fre- 
quent evacuation  by  pressure  of  the  contents  of  the  sac,  and  gentle 
massage.  In  the  experience  of  the  author  this  is  usually  sufficient ;  occa- 
sionally slitting  the  canaliculus  and  passing  probes  n)ay  be  neces.sary. 
If  pneumococci  are  present  in  the  secretion  mercurophen  (1-8000)  is 
valuable;  mercurochrome  may  also  be  used.  Argyrol  is  also  of  service 
especially  because  of  the  ease  with  which  it  passes  through  the  canal- 
iculus into  the  sac  especially  if  a  few  drops  are  placed  at  the  inner 
commissure  and  the  surface  over  the  sac  is  gently  massaged. 

Swelling  over  and  around  the  lacrimal  sac,  together  with  fistulous 
communication  into  it,  occasionally  will  subside  under  the  judicious 
use  of  a  compressing  bandage. 

In  addition  to  the  local  measures  already  mentioned  for  the  purpose 
of  producing  healing  in  cases  of  lacrimal  disease  associated  with  a 
catarrhal  condition  of  the  passages,  solutions  of  nitrate  of  silver,  and 
salicylic  acid,  iodoform,  aristol,  and  creolin  (1  per  cent.),  have  been 
advocated. 

In  acute  inflammation  with  abscess  formation,  quinin  and  iron  in 
the  form  of  Basham's  mixture  are  indicated;  in  syphilis,  with  disease 
of  the  bone  and  gummatous  deposit,  the  usual  drugs  should  be  ex- 
hibited; indeed,  it  is  important  to  make  a  Wassermann  test  in  stubborn 
cases  of  chronic  dacryocystitis,  even  though  no  nasal  deformity  (saddle 
nose)  or  ozena  be  present.  In  so-called  struma,  cod-liver  oil,  hypoplios- 
phites,  and  iron,  in  the  form  of  the  .syrup  of  tlie  iodid,  are  the  most 
trustworthy  remedies. 

Scrupulous  attention  to  the  nose  and  the  nasopharynx  is  necessary, 
and  any  local  lesions  which  present  themselves  must  be  treated.  In 
the  absence  of  a  special  line  of  practice  for  tiiis  region  excellent  results 
follow  a  simple  sjiraying  of  the  parts  with  Dobell's  solution  or  peroxid 
of  hydrogen  one-third,  water  two-thirds,  while  carrying  on  the  regula- 
tion measures  for  the  relief  of  the  lacrimal  disorder.  If  there  is  de- 
cided disease  of  the  region,  the  proj)er  treatment  of  file  part  with  the 
view  to  removing  diseased  structures  should  l)i'  undeitakeii.  In 
children  adenoids  should  be  removed.  The  importance  of  examiniiig 
accessory  nasal  sinuses  has  Ixsen  pointed  out,  especially  the  ethmoid 
and  tile  maxillary  sinus.  The  value  ol  .r-ray  examination  iias  been 
refencd  to. 

Oecasionall.v  it  will  liai)i)eii  thai  ;iilhtiii^li  ;i  (lud  has  been  tlior- 
oughly  opened,  the  probe  passes  readily,  and  tli<>  iicniid  used  in  tlie 
syringe  flows  freely  finni  tlie  nose,  the  epiphor.a  conliniics,  and  the  eve 


! 


EXTIRPATION  OF  THE  LACRIMAL  SAC  629 

fairly  swims  in  tears.  In  such  circumstances  a  probe  should  be  passed 
into  the  nose  and  the  entrance  of  the  duct  into  the  inferior  meatus 
properly  exposed  by  means  of  a  nasal  speculum.  Quite  often  it  will  be 
seen  that  a  thickening  of  the  duct  entrance,  or  perhaps  a  valve-like  flap 
of  mucous  membrane,  occludes  the  passage.  This  is  pushed  aside  by 
the  probe  or  forced  aside  by  the  liquid  when  it  is  injected,  but  entirely 
stops  the  flow  of  the  tears.  This  simple  precaution  will  sometimes 
lead  to  the  discovery  of  the  cause  of  failure  to  relieve  cases  which  have 
stubbornly  resisted  treatment. 

If  a  fistula  remains,  this  may  sometimes  be  closed,  as  already  stated, 
by  compression.  In  the  event  of  failure,  freshening  of  the  edges  and 
the  galvanocautery  may  be  tried,  the  surrounding  pouting  granulations 
being  removed  by  scraping.  The  capillary  fistulas  are  productive  of 
no  inconvenience  and  may  be  allowed  to  remain  undisturbed. 

Extirpation  of  the  lacrimal  sac  is  indicated,  and  usually  yields  good 
results  in  many  cases  of  chronic  dacryocystitis.  It  may  be  employed 
if  conservative  and  ordinary  surgical  measures  have  failed,  if  the  pa- 
tient cannot  or  will  not  devote  sufficient  time  to  treatment,  if  there  is 
an  impassable  stricture,  if  an  operation  on  the  eyeball  is  speedily 
necessary,  if  there  is  a  serpiginous  ulcer  of  the  cornea,  and  in  cases  of 
caries  of  the  lacrimal  bone.  The  operation  is  further  indicated  in  those 
whose  occupation  exposes  them  to  corneal  injury  (Axenfeld)  and  in 
insane  patients.  The  operation  is  so  satisfactory  in  its  results  that,  in 
the  author's  opinion,  it  should  in  large  measure  replace  the  use  of 
probes  and  the  other  measures  which  have  been  described.  If,  subse- 
quentl}'-,  the  epiphora  is  annoying,  extirpation  of  the  lacrimal  gland  has 
been  performed,  and  was  especially  advocated  by  C.  R.  Holmes.  In 
place  of  complete  excision,  removal  of  the  palpebral  gland  may  be  tried. 
The  author  has  not  found  it  necessary  to  employ  either  of  these  pro- 
cedures for  this  purpose.  (For  methods  of  operating,  see  page  759). 
Usually,  however,  as  the  conjunctiva  resumes  its  normal  condition, 
the  epiphora,  under  ordinary  conditions  at  least,  ceases  to  be  annoying, 
and  often  disappears.  In  place  of  excision  of  the  lacrimal  sac  other 
methods  of  operating  (intranasal  drainage)  in  cases  of  dacryocystitis 
are  preferred  by  many  surgeons  (page  761). 


CHAPTER  XXI 
DISEASES  OF  THE  EYEBALL  AND  ORBIT 

Congenital  Anomalies. — Anophthalmos,  or  complete  absence  of 
one  or  both  eyes,  is  an  affection  which,  hke  the  other  congenital  anoma- 
lies, more  frequently  is  double  than  one  sided.  A  child  born  without 
ej'es  may  be  healthy  and  well  developed  in  other  respects,  or  may  be  the 
subject  of  additional  congenital  deformities.  The  palpebral  fissures 
are  small,  the  lids  usually  deficient  in  size,  sunken,  and  upon  their 
separation  the  empty  orbit  is  revealed.  Usuallj'  (always,  according 
to  some  authors)  careful  dissection  will  expose  a  rudimentary  eyeball 
at  the  apex  of  the  orbit.  Sometimes  cysts  of  bluish  hue  are  con- 
nected with  rudimentary  ej'cs,  the  cyst  being  evident  in  the  lower  part 
of  the  orbit  or  the  lower  lid — orhitopalpebral  cyst.  Retinal  elements 
are  present  in  a  cyst  of  this  character. 

The  most  reasonable  explanation  of  this  anomaly  is  that  no  pri- 
mary optic  vesicle  has  budded  out  from  the  anterior  primary  encepha- 
lic vesicle,  or  that,  having  budded  out,  it  has  failed  to  form  a  secondar}^ 
optic  vesicle. 

Microphthalmos  and  megalophthalmos  are  anomalies  of  the  globe  to 
which  reference  has  been  made. 

Cyclopia  is  a  congenital  malformation  characterized  by  a  fusion  of 
the  orbits  and  the  two  eyes  in  the  middle  of  the  face,  so  that  there  is 
only  one  eye  situated  in  the  place  normally  occupied  by  the  root  of  the 
nose. 

General  Symptoms  of  Orbital  Disease. — Two  symptoms  are  so 
constantly  present  that  they  may  be  said  to  be  essential  to  th(>  cliiiical 
picture  of  most  of  the  affections  of  the  orbit: 

1.  Proptosis  or  Exophthalmos. — This  consists  of  more  or  h^ss  pro- 
trusion and  displacement  of  the  globe. 

2.  Lmmobility  of  the  Eyeball.- — This  may  lie  complete  or  partial,  ami, 
if  vision  is  unaffected,  the  limitation  of  the  movements  of  the  eye  is 
associated  with  diplopia.  Coiuplete  immobility  may  Ix^  differentiated 
from  a  similar  condition  due  to  palsy  of  all  exterior  ocular  nuisdes 
(oplitlialmopicgia  externa)  by  the  absence  of  ptosis  (Noyces). 

Tlic  following  signs  may  also  be  associated  with  orbital  disease: 

(a)  Chcmosis  of  the  conjunctiva,  either  iiiii\ crsal  or  else  localized 
upon  a  si)ecial  portion  of  the  globe,  indicating  llic  iicighborluKHl  of  the 
diseased  area. 

ih)  Redness,  sirilling,  and  itlcnia  of  the  eyelids,  ('Specially'  in  inliaiu- 
matory  affections  of  the  cellular  tissue  t)f  I  lie  oibit  and  disease  of  th(« 
accessory  nasal  sinuses. 

(c)  Pain,  most  noticeable  when  the  patient  a(teni|^ts  to  move  the 
eye  or  when  tlie  surgeon  palpates  (he  globe  and  presses  it  inward.     In 

630 


PEKIOSTITIS  631 

addition  to  the  pain  in  the  orbit  itself,  frontal  headache  is  a  common 
symptom,  especial!}^  if  the  sinuses  are  involved,  and  tenderness  on  pres- 
sure along  the  margin  of  the  orbit  and  accessible  portions  of  its  walls  is 
one  sign  of  disease  of  the  periosteum. 

(d)  Fluctuation  occurs,  but  not  constantly,  if  an  abscess  of  the  orbit 
has  formed. 

(e)  Disturbance  of  Vision. — In  some  cases  of  orbital  diseases  there 
is  no  disturbance  of  vision;  in  others  there  may  be  marked  changes  in 
the  e3'e-ground — papillitis  (choked  disk),  atrophy,  hemorrhages,  and 
vasculitis  or  perivasculitis. 

Periostitis  of  the  orbit  is  both  acute  and  chronic,  and  in  the  acute 
type  appears  either  as  a  localized  affection  or  as  a  diffuse  suppurative 
process. 

The  symptoms  of  acute  locahzed  periostitis  are  pain,  tenderness 
over  the  seat  of  the  disease,  usually  the  margin  of  the  orbit,  injection 
and  chemosis  of  the  conjunctiva,  and  some  swelhng  of  the  hds  and  pro- 
trusion of  the  ball.  In  the  diffuse  variety  of  the  disease  all  the  fore- 
going sj'mptoms  are  much  aggravated,  and  there  may  be,  in  addition, 
fever,  general  headache,  delirium,  and  stupor.  Periostitis  of  the  roof 
of  the  orbit  is  fraught  with  special  danger  on  account  of  its  proximity 
to  the  cranial  cavity.  In  such  a  case  the  differential  diagnosis  between 
it  and  an  orbital  celluUtis  becomes  extremely  difficult.  In  fact,  the 
cellular  tissue  is  associated  with  the  periosteum  in  the  inflammation. 
A  subperiosteal  abscess  may  form  and  become  encapsulated  or,  passing 
forward,  burst  through  the  skin  of  the  eyehd  or  at  the  angles  of  the 
orbit  and  form  an  orbital  fistula.  Other  situations  of  an  abscess  may 
be  between  the  periosteum  and  the  muscles,  -^-ithin  the  muscle  cone  and 
in  the  orbital  fat  (see  also  page  633). 

In  chronic  periostitis  there  are  deep-seated  pain,  often  worse  at 
night,  tenderness  on  pressing  the  ej^eball  backward,  thickening  of  the 
tissue  beneath  the  orbital  margin,  and  swelling  of  the  hds  and  conjunc- 
tiva, although  the  latter  symptoms,  together  with  proptosis,  may  be 
absent. 

According  to  ]\Iracek,  syphihtic  periostitis  most  frequently  attacks 
the  orbital  margins,  and  maj'  occur  in  a  gummatous  or  a  sclerosing  form. 
It  less  commonly  involves  the  orbital  walls  behind  Tenon's  capsule,  and 
is  then  generalh'  gummatous  in  tj'pe.  The  site  is  usually  in  the  upper 
or  outer  wall,  and  the  disease  causes  trigeminal  neuralgia,  worse  at 
night,  and  restriction  in  the  mobihty  of  the  globe,  with  squint  and 
diplopia.  Optic  neuritis  may  occur.  Tuberculous  periostitis,  especi- 
ally in  children,  is  usualh^  situated  at  the  upper  and  outer  or  lower  and 
outer  orbital  margins. 

The  causes  of  pei'iostitis,  especially  of  the  chronic  form,  in  addi- 
tion to  syphilis,  in  which  disease  it  is  sometimes  a  secondary,  but  more 
often  a  late,  manifestation,  are  rheumatism,  tuberculosis,  injuries  and 
affections  of  the  sinuses,  notably  the  frontal  and  the  ethmoid.  Syphi- 
litic periostitis  is  more  common  in  adults  than  in  children,  but  may 
attack  the  latter  (periostitis  with  hereditary  syphilis). 


632 


DISEASES    OF    THE    ORBIT 


The  prognosis  deiK'iid.s  upon  the  type  of  the  disease.  If  locaUzed, 
this  is  favorable;  if  diffuse  and  suppurative,  not  onh'  may  extensive 
implication  of  the  tissues  surrounding  the  globe  leave  permanent  dis- 
abilities and  deformities  (exophthalmos,  nmscle  palsy,  optic-nerve 
atrophy,  necrosis),  but  the  inflanunation  maj'  extend  to  the  meninges 
of  the  brain  and  cause  death. 

Chronic  periostitis  may  last  for  months,  and  in  any  type  fistulas, 
necrosis,  and  caries  of  the  bone  are  the  common  result.  Periostitis  due 
to  syphilis  presents  the  most  favorable  prognosis. 

Treatment. — ^Tlie  constitutional  treatment  depends  upon  the  cause, 
and  includes  the  iodids  and  salicylates  in  rheumatic  cases,  and  the 
use  of  mercurials  and  salvarsan  in  syphilitic  cases. 

The  surgical  treatment  of 
acute  periostitis  consists  in  an 
incision  into  the  affected  area 
and  evacuation  of  the  pus;  in 
short,  the  treatment  is  the  same 
as  that  applied  to  acute  perio- 
steal disease  elsewhere  located. 
The  relation  of  periostitis  to 
sinus  disease  demands  a  careful 
examination  of  the  sinuses  and 
treatment  according  to  the 
findings. 

Caries  and  Necrosis. — 
(Varies  is  prone  to  attack  the 
margin  of  the  orbit,  especially 
the  lower  and  outer  part,  and 
may  be  due  to  syphilis  or 
tuberculosis.  An  injury  often 
is  the  exciting  cause. 

The  symptoms  of  jieriostitis 
are  present,  suppuration  de- 
velops, the  abscess  comes  to  the  surface  through  the  hd  over  the  dis- 
eased area,  rupture  occurs,  with  the  discharge  of  pus,  a  fistula  forms, 
surrounded  by  granulations,  and  through  this  a  probe  will  detect  the 
softened  Ijone.  Very  decided  deformity  of  the  lid  may  be  t)ccasioned, 
most  commonly  in  the  form  of  an  ectropion  (compare  Figs.  97  and  100). 
Caries  of  the  orl>it  is  most  common  in  children,  and,  as  has  been 
pointed  out,  sel(!cts  the  margin  of  the  orbit  for  its  site,  although  it 
may  occur  in  the  roof,  in  which  ca.se  it  ix'comes  a  complication  en- 
dang<'ring  life,  owing  to  the  proximity  of  the  brain.  The  iiiflaMUiia- 
tion  may  spread  to  the  oibital  tissues  and  cause  exophthalmos  ;iiid 
neuroretinitis. 

Necrosis  of  the  orbit  is  much  less  common,  and  its  immediate  cause 
is  an  (jsteitis  occurring  as  a  (•onse(]uen('c  of  acute  pciiostitjs.  A  frag- 
ment of  bone  completely  separated  by  a  fracture  from  the  periosteal 
.surroundings  w(»ul(l  |)rob!ibly  undeigo  necrosis,  ami  the  lougli  use  ol 


-liij.      (^aiU'aof  tliu  orljil  (fruiu  u  iKiticut 
in  the  University  Hospital). 


CELLULITIS 


633 


probes  may  cause  mortification  of  the  delicate  lacrimal  bone.     Necrosis, 
unlike  caries,  is  more  common  in  adults. 

Treatment. — This  consists  of  the  remedies  recommended  in  the 
treatment  of  periostitis,  and,  as  caries  is  a  very  chronic  affection  and 
most  common  in  strumous  (tuberculous)  subjects,  cod-Hver  oil,  phos- 
phates, and  iodid  of  iron  should  be  included  in  the  constitutional 
measures,  and  should  be  exhibited  for  long  periods  of  time. 

The  local  treatment  during  the  early  ulcerative  stage  of  caries  con- 
sists of  evacuation  of  foci  of  suppuration,  careful  cleansing  with  anti- 
septic solutions,  and  drainage.  Considerable  caution  is  necessary 
before  resorting  to  the  removal  of  the  diseased  bone  with  a  gouge, 
because  the  process  is  essentially  chronic  and  may  be  aggravated  by 
the  manipulations  of  the  instrument;  but  roughened  bone  should  be 
scraped  with  a  sharp  spoon  and  the  diseased  portions  thoroughly  re- 
moved. If  the  roof  of  the  orbit  is  affected,  great  care  is  necessary  lest 
the  cranial  cavity  be  penetrated.  If  a  piece  of  the  orbital  wall  has 
undergone  necrosis,  this  should  be  removed  when  it  has  become  loose 
or  detached.  The  regions  overljang  the  sinuses  should  be  carefully 
examined. 

Cellulitis  {Phlegmon  of  the  Orbit). — There  are  several  varieties  of 
inflammation  of  the  cellulofatty  tissue 
of  the  orbit.  Thus  the  inflammation 
may  be  acute,  subacute,  or  chi-onic, 
unilateral  or  bilateral,  and  finally  it 
may  undergo  resolution  or,  as  more 
commonl}'  is  the  case,  terminate  in 
suppuration. 

In  the  mild  form  the  symptoms  are 
dull  pain,  swelhng  of  the  hds,  shght 
exophthalmos  and  diplopia,  without 
inflammatorj'  s^^mptoms  and  without 
constitutional  disturbance. 

In  the  acute  phlegmonous  variety 
of  the  disease  there  are  chills,  fever, 
deep-seated  pain,  most  marked  upon 
attempting  to  move  the  eyes,  general 
headache,  exophthalmos,  hmitation  in 
the  movements  of  the  eye  (which  may 
become  entirely  fixed),  and  swelHng  and 
edema  of  the  lids,  together  with  h3'per- 
emia  and  chemosis  of  the  conjunctiva. 
The  last  two  symptoms  are  so  severe  at  times  as  to  give  at  first  sight 
the  general  impression  of  a  violent  attack  of  purulent  conjunctivitis 
(Fig.  261). 

In  the  earher  stages  vision  is  not  usually  affected,  but  later  there 
may  be  optic  neuritis  followed  by  atrophy,  dilatation  of  the  pupil, 
anesthesia,  and  even  ulceration  of  the  cornea,  and,  indeed,  in  severe 
eases  the  eyeball  may  suppurate.     In  certain  types  of  orbital  celluHtis 


Fig.  261. — From  a  photograph  of 
a  patient  in  the  Philadelphia  General 
Hospital  suffering  from  double  or- 
bital cellulitis,  the  result  of  erj'sipelas. 


634  DISEASES     OF     THE     ORBIT 

extensive  intra-ocular  changes  occur,  with  hemorrhages  and  vascular 
alterations,  due  to  compression  of  the  central  vessels  of  the  retina 
producing  stoppage  of  the  circulation  and  edema  and  exudation  into 
the  retina  (Knapp).  Bhndness  from  orbital  abscess  may  be  due  to 
retrobulbar  necrosis  of  the  optic  nerve,  caused  by  thrombosis  of  the 
pial  vessels  and  of  the  central  vessels  (Bartels).  Fluctuation  finalh' 
develops;  pointing  usually  occurs  below  the  inner  portion  of  the 
supra-orbital  ridge. 

The  symptoms  of  chronic  abscess  are  much  less  violent  and  distinc- 
tive than  those  just  described.  They  maj',  indeed,  be  mistaken  for 
other  morbid  conditions,  cspccialh^  as  the  abscess  is  commonly  asso- 
ciated with  diseased  bone  or  periosteum  in  scrofulous  subjects,  or  may 
occur  in  them  from  an  injury  or  the  presence  of  a  foreign  body. 

The  causes  of  orbital  celluhtis  are  various.  It  may  be  traumatic 
or  may  be  due  to  exposure  to  cold;  it  may  follow  in  the  wake  of  scar- 
latina, measles,  typhoid  fever,  or  influenza;  or  it  may  be  the  result  of 
a  meningitis.  The  most  violent  types  of  orbital  cellulitis  occur  with 
facial  erysipelas.  In  these  instances  the  affection  is  usually  double. 
The  extension  of  inflammation  from  diseased  teeth  or  suppuration  in 
the  ethmoid  cells,  sphenoid,  or  antrum  of  Highmoie  may  cause  the 
affection.  Birch-Hirschfeld's  investigation  demonstrates  that  the 
largest  number  of  orbital  inflammations  (about  60  per  cent.)  are  due  to 
accessory  sinus  inflammation.  The  infection  is  conveyed  from  the 
sinus  to  the  orbital  contents  by  means  of  septic  thrombosis,  thrombo- 
phlebitis, lymphangitis,  or  erosion  of  the  bony  partition.  Finally,  a 
certain  number  of  cases  are  metastatic,  and  develop  in  the  course  of 
pyemia,  especially  puerperal  septicemia.  During  the  past  war  a 
number  of  cases  of  metastatic  orbital  abscess  occurred  in  association 
with  osteomyelitis,  chiefly  of  the  femur.  Some  of  them  began  with 
fixation  of  the  globe,  slight  (exophthalmos,  but  with  no  iiitlannnatory 
symptoms  evident  for  several  daj's.  The  association  of  orbital  cellu- 
litis with  periostitis  has  already  been  referred  to,  and  a  certain 
amount  of  cellulitis  occurs  whenever  there  is  a  general  iiifiammatiou 
of  the  globe. 

Progress  and  Prognosis. — In  mild  cases  tli(>  prognosis  is  favorable; 
in  severe  cases,  unfavorable;  and  in  double  cases,  especially  those  which 
have  originated  under  the  influence  of  erysipelas,  usually  fatal.  Al- 
though the  pus  ma}^  make  its  exit  through  the  conjunctiva  or  eyelid, 
it  may  also  pass  ])ackward  through  the  sphenoid  fissure.  In  pyemic 
cases,  and,  indeed,  in  the  course  of  any  severe  inilanunation  of  the 
cellulofatt}^  tissue  of  the  orbit,  pfdcbitis  of  the  orbital  reins  may  become 
a  comphcation  and  extend  to  the  cavernous  sinus,  leading  to  a  fatal 
termination.  If  the  disease  passes  to  the  cavcMiious  simis  upon  the 
opj)()site  side,  the  othei-  eye  also  becomes  invoKcd  and  exophth.ahnos 
is  evident. 

In  framing  a  prognosis  it  is  necessaiy  to  consider  tlu>  elYect  of  the 
disease  upon  the  eyesight  and  upon  the  life  of  the  patient.  Sight  may 
be  impaired  oi*  destroyed  l»y  tiie  (l('\<>lopinenl  of  optic  neuritis,  optic- 


THROMBOSIS  OF  THE  CAVERNOUS  SINUS         635 

nerve  atrophy,  exudation  and  hemorrhages  into  the  retina,  or  by  sup- 
puration of  the  cornea:  hfe  may  be  endangered  by  an  extension  of  the 
suppurative  process  into  the  cranial  cavity,  or  bj'  the  original  malady 
which  caused  the  celluUtis. 

Treatment. — -The  general  treatment  should  include  supporting 
measures  and  iron  and  quinin,  Occasionallj'  the  pus  points  in  the  con- 
junctival sac  and  may  be  evacuated  by  an  incision  through  the  con- 
junctiva between  the  ball  and  the  side  of  the  orbit,  care  being  taken 
not  to  injure  the  ocular  muscles  and  to  secure  good  drainage  afterward. 
In  deeper  situations  the  purulent  focus  is  best  reached  by  a  curved  inci- 
sion made  over  the  orbital  ridge  w^hich  divides  the  periosteimi,  which  is 
next  separated  with  an  ordinary  bone  elevator,  kept  well  between  the 
bone  and  the  periosteum,  thus  avoiding  the  levator,  the  tendon  of  the 
superior  obhque,  and  the  lacrimal  gland.  If  pus  does  not  immediately 
present,  the  depth  of  the  orbit  must  be  explored  with  a  probe  until  the 
pocket  of  pus  is  found,  and  evacuated  by  an  incision  through  the  peri- 
osteum. Drainage  may  be  secured  '^dth  iodoform  gauze  or  an  ordinary 
drainage-tube.  The  position  of  the  original  incision  is  determined  by 
the  probable  situation  of  the  pus;  that  is  to  say,  whether  it  is  made 
along  the  upper,  lower,  inner,  or  outer  orbital  margin.  If  the  source 
of  the  pus  is  from  the  ethmoid,  the  orbital  plate  of  this  bone  should  be 
perforated,  carious  bone  and  necrotic  tissue  removed,  and  a  drainage- 
tube  carried  from  the  orbit,  through  the  ethmoid,  into  the  nose,  which 
not  only  secures  an  adequate  drainage,  but  permits  the  subsequent 
washing  out  of  the  tract.  Indeed,  the  frequent  association  of  sinus  dis- 
ease with  orbital  celluhtis  usuall}^  demands  that  the  incision  shall  be 
so  placed  and  sufficiently  broad  to  render  exploration  of  the  orbital 
walls  practicable  and  treatment  of  the  affected  sinus  (frontal  or  eth- 
moid) possible. 

Inflammation  of  the  Oculo=orbital  Fascia  {Tenonitis). — This 
affection  is  characterized  by  swelling  of  the  upper  lid.  the  discoloration 
of  the  tumefied  hd  being  hmited  to  its  tarsal  portion  (Pincus) ;  pain  on 
the  sHghtest  movement  of  the  eye,  some  proptosis  and  hmitation  of 
movement,  together  with  the  appearance  of  a  water}"  nodule  or  vesicle 
situated  over  one  of  the  recti  muscles;  in  other  cases  the  chemosis  may 
be  more  general.  Primarj'  serous  tenonitis  is  a  rare  disease,  about 
40  cases  being  on  record  (Birch-Hirschf eld) .  Tenonitis  may  follow  an 
injury  or  an  operation — for  instance,  tenotomy;  in  some  instances  it  is 
due  to  rheumatism,  possibly  to  tuberculosis,  and  it  has  been  noted  as 
a  sequel  of  diphtheria,  typhoid  fever,  and  epidemic  influenza,  and  may 
be  caused  by  syphilis.  Lesions  almost  exactly  analogous  to  those  of 
tenonitis  are  occasionally  caused  by  an  intra-ocular  growth;  for  ex- 
ample, a  sarcoma  (see  page  390). 

The  treatment  should  consist  of  warm  fomentations  and,  according 
to  the  indications,  iodid  of  potassium  or  the  sahc3'lates. 

Thrombosis  of  the  Cavernous  Sinus. — During  phlegmonous 
inflammation  of  the  orbit  there  may  be  thrombosis  of  the  orbital  veins, 
and  extension  from  them  to  the  cavernous  sinus  or  to  the  other  sinuses 


636  DISEASES    OF    THE    ORBIT 

of  the  brain.  Primary  traumatic  non-infective  thrombosis  of  the  cav- 
ernous sinus  has  been  described  by  H.  Knapp.  Septic  thrombosis  of 
the  cavernous  sinus  may  arise  as  the  resuh  of  any  infected  lesion  in  the 
area  drained  by  the  ophtliahuic  vein  or  its  branches,  for  examph-.  pus- 
tules on  the  face,  nostrils,  or  eyelids,  and  from  purulent  affections  of 
the  accessory  sinuses  and  rhinopharj'nx,  and  from  erysipelas  and 
wounds.  According  to  St.  Clair  Thomson,  next  to  disease  of  the 
sphenoidal  sinus,  pyogenic  infection  from  the  ear  is  the  most  common 
cause  of  thrombosis  of  the  cavernous  sinus.  The  ocular  sj-mptoms 
which  accompanj''  cavernous  sinus  thrombosis  are:  proptosis,  edema 
of  the  eyelids  and  chemosis  of  the  conjunctiva,  haziness  and  anesthesia  of 
the  cornea,  and  partial  or  complete  ophthalmoplegia — that  is,  gradual 
involvement  of  the  third,  fourth,  and  sixth  nerves — venous  engorgement 
of  the  retinal  veins,  and  neuroretinitis.  The  general  symptoms  include 
headache,  fever,  delirium,  coma,  and  convulsions.  While  ocular  mani- 
festations of  sinus  thrombosis  may  be  mistaken  for  exophtiialmos 
from  other  causes,  for  example,  injury,  fractures  of  the  skull  and  orlntal 
tumor,  the  history  and  symptoms  are  so  distinctive  that  such  an 
error  should  always  be  avoided.  Orbital  celluUtis  is  not  so  readily 
differentiated;  the  absence  of  cerebral  symptoms  in  the  orbital  affec- 
tion (in  most  of  the  cases)  would  be  an  important  distinguishing 
feature.  The  prognosis  of  infected  cavernous  sinus  thrombosis  unless 
drainage  can  be  secured,  is  fatal.  The  feasibiUty  of  drainage  has 
been  demonstrated  (Hartley,  Ballance  and  others).  The  approach 
has  been  (quoting  Borland  Smith)  through  the  Hartlej'-Krause  Gas- 
serian  ganglion  route,  through  the  orbit  (advocated  by  ^Mosher)  and 
through  the  petrous  portion  of  the  temporal  bone  (Borden). 

Tumors  and  Cysts  of  the  Orbit. — Tumors  have  been  divided  by 
systematic  writers  into  those  which  originate  in  the  orbit,  but  are 
unconnected  with  the  globe  of  the  eye;  those  which  arise  from  the 
periosteum  or  bony  walls  of  the  orbit;  those  which  commence  in  the 
cavities  close  to  the  orbit;  and  those  which  originate  in  some  vas- 
cular disease  within  the  cavity  of  the  orbit  or  the  neighboring  por- 
tions of  the  cranial  cavity,  and  which  usualh'  give  rise  to  pulsating 
exophthalmos. 

Two  classes  of  tumors,  namely,  those  wiiicli  aiise  troni  the  optic 
nerve  and  those  which  arise  from  the  lacrimal  gland,  are  sometimes  in- 
cluded among  the  orbital  growths.  T}i(\v  have  already  been  discussed 
in  anotlu^r  section. 

The  mitiirc  of  orbital  t  iiniors  is  either  benign  or  malignant .  and  they 
may  be  congcMiital  or  ac(iuired,  primary  or  metastatic,  .\fter  enuclea- 
tion of  an  eyeball  for  sarcoma  of  the  choroid  there  may  be  a  recur- 
rence of  the  growth  in  the  orbital  tissue. 

Symptoms.  These  vary  according  to  the  position,  size,  and  density 
of  the  tumor,  but  in  general  terms  .aic  those  which  ha\('  been  narrated 
as  more  or  less  common  to  all  diseases  of  t he  orbit .  Wit  h  regard  to  t he 
protrusion  it  may  be  said  th.at  a  tumor  within  the  cone  of  the  recti 
muscles  is  apt  to  cause  a  forwaid  (hsplaceiiienl  of  the  glolie,  while  one 


! 


TUMORS   AND   CYSTS   OF   THE   ORBIT  637 

situated  outside  of  this  cone  may  displace  the  eyeball  in  some  particular 
direction. 

Considerable  proptosis  ma}^  occur  under  the  influence  of  an  orbital 
tumor  without  causing  the  globe  to  protrude  between  the  fissure  of  the 
lids.  This  is  due  to  the  fact  that  the  Hds  are  extensible  and  accommo- 
date themselves  to  the  increasing  volume  behind  them;  finally,  how- 
ever, the  protrusion  may  be  so  great  that  the  Hds  can  no  longer  close 
over  the  prominent  ball. 

Prognosis. — This  depends  upon  the  nature  of  the  tumor,  the  den- 
sity of  its  tissue,  the  rate  of  its  growth,  and  the  availability  of  surgical 
interference. 

Treatment. — In  deahng  (by  removal)  with  benign  tumors  and  some 
encapsulated  sarcomas  the  eyeball,  if  uninvolved,  should  be  allowed  to 
remain,  if  possible.  In  most  of  the  cases  of  mahgnant  growths  of 
the  orbit,  and  where  beginning  involvement  of  the  surrounding  tissue 
is  evident  or  cannot  surely  be  excluded,  exenteration  of  the  entire  orbital 
contents  is  required  (page  719).  According  to  C.  S.  Bull,  encapsulated 
tumors  of  the  orbit  may  be  removed  with  the  almost  certain  hope  of 
favorable  result,  while  non-encapsulated  tumors  present  an  unfavor- 
able prognosis.  After  removal  of  a  mahgnant  growth  or  in  the  event 
of  a  return,  the  a;-rays  or  radium  (page  186)  should  be  employed. 
Radium  may  be  used  with  success  in  the  treatment  of  orbital 
growths  independently  of  surgical  interference.  As  was  pointed  out 
by  Panas,  Snell,  and  others,  certain  tumors  of  the  orbit,  probably 
lymphomas,  occasionally  disappear  under  medicinal  treatment — for 
example,  iodid  of  potassium,  arsenic,  etc.  Hence  the  necessity  of 
careful  medication  before  surgical  measures  are  tried.  The  difficulty 
of  distinguishing  an  orbital  tumor  from  a  chronic  inflammatory 
process  is  often  great  and  no  method  of  diagnosis  should  be  omitted, 
especially  careful  examination  of  the  accessor}^  sinuses.  In  this  regard 
x-ray  examination  is  important. 

1.  Tumors  which  Originate  in  the  Tissues  of  the  Orbit. — These  in- 
clude cysts,  fibromas,  cavernous  and  simple  angiomas,  lymphangiomas, 
lipomas,  enchondromas,  lymphomas,  cyhndromas,  endothehomas, 
psammosarcomas,  and  the  various  other  types  of  sarcoma.  Discrete 
lymphoid  infiltration  of  the  orbit,  causing  proptosis,  has  been  reported 
by  Coats.  Carcinoma,  except  in  connection  with  the  lacrimal  gland, 
does  not  occur  in  this  situation  as  a  primary  tumor;  it  may,  arising 
from  the  Uds  or  conjunctiva,  grow  inward  and  involve  the  orbit  (page 
185).  In  a  total  of  68  cases  of  metastatic  carcinoma  of  the  choroid 
there  was  in  13  of  them  an  extra-ocular  extension  of  the  growth  from 
the  focus  in  the  choroid  (Shumway).  Metastasis  of  carcinoma  from 
distant  organs  to  the  ocular  muscles  has  been  described  (see  page  589). 
Adrenal  tumors  in  children,  usually  under  four  years  of  age,  with 
metastasis  to  the  orbit,  have  been  reported  (Quakenboss,  Verhoeff). 

Sarcomas  of  the  orbit  may  be  primary  or  metastatic  and  may 
present  the  various  types  of  cellular  structure  characteristic  of  these 
tumors.     Some  sarcomas  of  the  orbit  should  be  classified  with  the 


638 


DISEASES    OF    THE    ORBIT 


endotheliomas.  If  the  morbid  process  is  an  extensive  one,  radical 
removal  of  the  entire  contents  of  the  orbit  is  the  only  procedure,  and 
subsequently  the  x-rays  or,  preferably,  radium  should  be  employed. 
Even  in  inoperable  malignant  disease  of  the  orbit  pain  is  lessened  by 
the  application  of  the  x-rays,  and  the  complete  disappearance  of  sar- 
coma of  the  orbit,  without  operation,  under  the  influence  of  repeated 
applications  of  Ilontgen  rays  has  been  reported  (L.  W.  Fox),  and  rep- 
resents a  therapeutic  measure  deserving  of  the  most  thorough  trial. 
In  like  circumstances  radium  may  be  used  and  is  an  even  more  service- 
able agent.  Encapsulated  sarcomas  may  occasionally  be  removed 
with  preservation  of  the  eyeball.  Traumatic  sarcomas  offer  a  most  un- 
favorable prognosis,  and  operation  hastens  rather  than  retards  the  fatal 
issue.  Sarcomas  of  the  orbit  should  not  be  confounded  with  those 
which  arise  within  the  eyeball  and  have  burst  their  boundaries  (see 
page  391). 


Fig.  262. — Metastatic  sarcoma  of 
the  orbit  (from  a  patient  under  the 
care  of  Dr.  Wharton  in  the  ('hildren's 
Hospital). 


Fig.  263. — Sarcoma  of  the  orbit  spring- 
ing from  the  periosteum  over  the  great  Nving 
of  the  sphenoid. 


Berlin  divided  orbital  cysts  into  two  principal  groups,  cephaloceles 
and  true  cysts.  C'ephaloceles  are  located  at  the  root  of  the  nose,  and 
extend  to  the  brow,  nasal  cavities,  or  orbit.  Ciiaracteristic  of  cephalo- 
celes and  meningoceles  is  the  fad  (hat  they  present  at  the  inner  side 
of  the  orbit,  that  they  fluctuate  and  are  transparent.  True  cysts 
should  be  divided,  according  to  Klingelhoffer,  into  (a)  true  cysts  from 
constriction,  wiiich  are  derived  from  congenital  meningoceles;  (6) 
extravasation-cysts — ^that  is  to  say,  blood-i-ysts,  hematomas,  etc.; 
(c)  (!xutlat ion-cysts,  which  are  very  rare;  (,</)  dermoiils,  wiiicli  aiX3  the 
most  frequent  cystic  tumors  growing  in  the  orbit;  (c)  mucous  cysts, 
whi(!h  may  communitrate  with  the  nose,  and  (/)  echinococcus  cysts. 
lOxtiavasated  blood  in  the  rctrol)ulbar  tissue  may  become  encapsulated 
and  siiiiulalc  a  blood-cyst,  and  subperiosteal  Itjood-cysts  have  been 
(lesciil)e(l  (  Denig,  i.amb). 


TUMORS  AND   CYSTS   OF  THE   OEBIT  639 

Occasionally  a  simple  incision  suffices  to  cure  a  cyst  if  the  cavity 
is  afterward  frequently  syringed  with  an  astringent  or  antiseptic  lotion. 
After  the  evacuation  of  a  dermoid  cyst  Buller  recommended  the  intro- 
duction of  a  crystal  of  nitrate  of  silver  or  tincture  of  iodin  to  destroy  the 
cyst  wall.  Usually  the  cyst  wall  must  be  dissected  out,  and,  if  semi- 
solid or  sohd  contents  are  present,  entire  removal  is  necessary.  Care 
must  be  taken  not  to  confound  a  cephalocele  with  an  orbital  cyst. 

2.  Tumors  which  Arise  from  the  Periosteum  or  Bony  Walls  of  the 
Orbit. — These  include: 

(a)  Sarcomas,  which  arise  from  the  periosteum. 

(6)  Thickening  of  the  periosteum,  which  may  simulate  a  true  tumor, 
especially  if  the  underlying  bone  is  hypertrophied  (hyperostoses:  these 
may  be  multiple  or  diffuse),  and — 

(c)  Exostoses. — The  latter  are  very  hard  tumors  having  an  ivory- 
like shell  and  a  nucleus  of  spongy  bone,  their  anatomic  structure  in 
general  being  like  that  of  the  osteomas  proceeding  from  adjacent 
cavities.^  All  orbital  osteomas  grow  slowly — the  external  exostoses 
more  slowly  than  the  bony  tumors  which  originate  from  the  frontal 
and  ethmoid  sinuses.  They  spring  from  the  periosteum,  and  are  gener- 
ally found  at  the  upper  border  of  the  orbit,  although  they  may  occur  at 
any  portion  of  the  orbital  border,  and  are  recognized  by  their  dense 
hardness  and  evident  connection  with  the  bone. 

They  may  arise  from  injury;  sometimes  they  are  congenital,  and 
often  their  origin  is  obscm-e.  Occasionally  a  sarcoma  (a  psammo- 
sarcoma,  as  in  a  case  under  the  care  of  the  author) ,  may  be  completely 
encased  in  a  thin  osseous  capsule  and  simulate  an  exostosis  (Fig.  358). 

The  operation  for  the  removal  of  an  exostosis,  after  its  exposure  by 
suitable  incisions  of  the  soft  parts  and  periosteal  covering,  consists  in 
drilhng  it  away  at  the  base  and  completing  the  separation  by  means  of 
a  hammer  and  chisel.  An  electric  drill  and  saw  is  of  special  service  in 
these  operations. 

3.  Tumors  which  Arise  in  Cavities  or  Tissues  Close  to  the  Orbit. — 
These  include : 

(a)  Encephalocele,  a  rare  condition,  which  appears  in  the  form  of  a 
somewhat  pulsating,  fluctuating  protrusion  at  the  inner  angle  of  the 
orbit;  it  is  of  congenital  origin. 

(6)  Nevi,  epithelioma,  and  lupus,  which  may  extend  from  the  skin 
of  the  face  into  the  orbit. 

(c)  Polypi  from  the  nasal  chambers  and  surrounchng  sinuses,  and — 

(d)  Osteomas  of  the  frontal  and  ethmoid  sinuses. 

An  osteoma  consists  of  a  dense  growth,  with  predominance  of  the 
ivory  shell,  and  onl}^  a  trace  of  spongy  tissue  (occasionally  the  reverse 
occurs).  Generally  the  surface  is  covered  with  a  dehcate  connective- 
tissue  envelope,  and  part  of  this  may  be  the  seat  of  polypoid  growi:hs 
coming  from  the  remains  of  the  mucous  membrane  which  atrophies 
under  pressure  of  the  tumor. 

^  For  a  valuable  paper  by  J.  A.  Andrews,  on  "Osteomas  of  Orbit,"  see  Medical 
Record,  September  3,  1887. 


640 


DISEASES    OF    THE    ORBIT 


According  to  Andrews,  osteoma  of  the  frontal  sinus  first  makes 
its  appearance  by  a  tumor  at  the  upper  inner  angle  of  the  orbit,  and 
may  be  associated  with  the  formation  of  polypi  and  suppuration  of  the 
sinus.  One  which  grows  from  the  ethmoid  sinus  first  appears  at  the 
inner  angle  of  the  orl^it,  and  the  eyeball  is  displaced  lateralh'. 

If  an  osteoma  springs  from  the  antrum  of  Highmore,  the  tumor 
appears  behind  the  lower  eyelid,  and  the  eyeball  is  displaced  upward; 
if  it  arises  in  the  sphenoid  fissure,  sight  is  affected  by  comnression  of 
the  optic  nerve. 

Extirpation  of  osteomas  in  the  sinuses  is  attended  with  consideral)le 
risk,  and  a  number  of  fatal  cases  are  on  record. 

4.  Tumors  which  Originate  in  Some  Vascular  Diseases  within  the 
Cavity  of  the  Orbit  or  in  the  Neighboring  Portions  of  the  Cranial 
Cavity  (Pulsating  Exophthalmos). — Under  the  name  pulsating  exoph- 
thalmos a  number  of  conditions 
of  diverse  origin  have  been 
described,  and  more  than  300 
cases  are  now  on  record.  The 
conspicuous  symptoms  wliich 
may  arise  in  the  course  of  this 
disease,  although,  naturally,  not 
all  of  them  are  present  in  each 
case,  are  as  follows:  E.xoph- 
thalmos,  most  frequently  with 
the  eye  displaced  outward  and 
downward;  bruit,  usually  heard 
over  the  eye  and  above  the 
orbit,  but  sometimes  audible 
over  the  whole  skull  and  evident 
to  the  patient  as  a  roaring,  hum- 
ming, buzzing,  or  hissing  sound; 
pulsation,  which  may  i)e  visible 
or  demonstrabU*  only  by  pal- 
pation, or  by  pressing  the  globe 
backward  into  the  orbit;  distention  of  the  veins  at  the  inner  angle  of 
the  orbit,  especially  enlargement  of  the  angular  vein,  and  of  tho.^^e  of 
the  lid  and  even  of  the  forehead  and  on  the  surface  of  the  conjunctiva; 
corneal  complications,  usually  in  the  form  of  exposure  keratitis;  fre- 
quently hyp(iremia  of  the  iris  and  rarely  actual  iritis;  connnonly 
hyperemia  of  the  nerv(^-hea(l,  and,  occasionally,  o|)ti('  neuritis  and 
even  choked  disk;  fre((uen11y  marked  distention  of  tlie  retinal  veins  and 
scattered  retinal  hemorrhages;  disturbances  of  ocular  motility,  some- 
times HO  extensive?  as  to  implicate  all  of  the  exterior  ocular  muscles, 
sometimes  only  one  or  other  of  them,  the  external  rectus  being  the  one 
most  fi('(|Mently  aiTectcd  where  a  single  muscle  is  involved;  occiusional 
involvement  of  the  trifacial,  of  tin-  facial,  and  disturbances  of  t.n-ste, 
smell,  and  hearing.  The  association  of  glaucoma  and  pulsating  ex- 
ophthalmos has  been  observed  (JOlschnig). 


Fig.  2G4. — Pulsating  exophtlialnios  (from 
a  case  under  the  care  of  Dr.  Kent  ^\'lleelock, 
Fort  Wayne,  Indiana). 


EXOPHTHALMIC  GOITER 


641 


Formerly  such  symptoms  were  regarded  as  evidence  of  true  aneu- 
ysm  of  the  ophthahnic  artery,  but  pulsating  exophthalmos  may  also  be 
due  to  a  vascular  tumor  or  an  intracranial  affection.  As  Rivington 
demonstrated,  the  affection  may  be  caused  b}^  an  extra-orbital  aneu- 
rysm of  the  ophthalmic  artery,  aneurysm  of  the  internal  carotid,  or  an 
aneurysmal  varix  involving  the  internal  carotid  and  the  cavernous 
sinus.  The  last-named  lesion — arteriovenous  communication — is  the 
one  most  frequently  responsible  for  these  phenomena.  Dilatation 
from  obstruction  of  the  ophthalmic  vein  may  cause  the  condition,  but 
aneurysm  by  anastomosis,  which  may  involve  the  orbit  by  spreading 
from  neighboring  parts,  is  not  accompanied  by  exophthalmos.  Trau- 
matism is  responsible  for  the  majority  of  the  cases,  being  the  essential 
cause  in  about  60  per  cent. 

Treatment. — This  has  included:  (1)  Ligation  of  the  larger  arteries 
of  the  neck:  (2)  operations  upon  the  orbit;  (3)  compression  of  the  com- 
mon carotid;  (4)  direct  compression  of  the  venous  swellings  of  the 
eyehds  and  the  angle  of  the  orbit;  (5)  gelatin  injections;  (6)  the  admin- 
istration of  certain  drugs  and  rest  in  the  recumbent  posture.  Of  these 
various  procedures,  Hgation  of  the  common  carotid  and  orbital  opera- 
tion furnish  the  most  satisfactory  results.  According  to  the  investi- 
gations of  the  author  and  Holloway  in  1907,  hgature  of  the  common 
carotid  had  been  performed  one  hundred  and  fifty  times,  with  cure  or 
improvement  in  64.6  per  cent.,  failure  in  25.3  per  cent.,  and  death  in  10 
per  cent,  of  the  cases;  in  a  certain  number  of  them,  about  10  of  the 
total  number,  both  carotids  had  been  ligated.  The  orbital  operations 
have  included  Hgation  of  the  superior  ophthalmic  vein,  of  the  inferior 
ophthalmic  vein,  of  the  angular  vein,  and  of  the  smaller  orbital  veins, 
and  the  results  in  almost  all  of  the  cases  have  been  good.  If  ligature  of 
a  common  carotid  fails  before  a  second  carotid  is  tied,  the  operation  of 
dissecting  out  and  tying  the  distended  superior  ophthalmic  vein  should 
be  performed.  If  there  is  a  distinct  venous  swelhng  in  the  orbit,  with 
evident  distention  of  the  angular  or  superior  ophthalmic  vein,  the  opera- 
tion of  choice  should  be  isolation,  ligature,  and  resection  of  this  venous 
channel.  It  is  not  without  danger,  and  the  author  is  aware  of  one 
fatal  case,  death  being  due  to  exten.sion  backward  of  a  thrombus  into 
the  brain.  Compression  of  the  common  carotid,  with  or  without  the 
administration  of  iodid  of  potassium,  has  been  successful  in  a  few  in- 
stances, and  may  be  tried  before  radical  surgical  means  are  resorted  to. 

Exophthalmic  Goiter  (Graves'  Disease;  Basedoiv's  Disease). — 
This  disease,  when  it  is  perfectly  developed,  is  characterized  by  three 
cardinal  sj^mptoms — enlargement  of  the  thyroid  gland,  palpitation  of 
the  heart,  and  prominence  of  the  eyeballs.  As  the  affection  should  be 
classified  with  diseases  of  the  ductless  glands,  the  student  is  referred 
for  a  full  consideration  of  the  subject  to  treatises  upon  the  practice  of 
medicine. 

Inasmuch,  however,  as  one  of  the  cardinal  symptoms — prominence 
of  the  eyeballs — is  a  very  marked  one,  and  as  there  are  certain  changes 
seen  especially  in  and  around  the  eyes,  a  few  words  may  be  added. 

41 


642  DISEASES    OF    THE    ORBIT 

Exophthalmos  varies  from  a  mere  prominence  of  the  eyeballs,  such,  for 
instance,  as  is  noticeable  in  a  highly  myopic  globe,  to  a  degree  of  pro- 
trusion so  great  tliat  the  eyelids  are  unable  to  close.  Excessive  epi- 
phora may  bo  present  as  an  early  sym[)tom — i.  e.,  before  exophthalmos 
appears  (IBerger).     Four  symptoms  should  be  searched  for: 

1.  Von  Graefe's  sign,  which  is  very  important  in  the  early  recog- 
nition of  the  disease.  Normally,  when  the  globe  is  turned  downward, 
the  upper  lid  moves  in  perfect  accord  with  it;  in  this  disease,  on  rolling 
the  eyeball  downward,  the  upper  lid  follows  tardily,  or  does  not  move 
at  all.  The  symptom  is  not  always  present,  but  it  may  be  noted  prior 
to  the  development  of  exophthalmos  or  at  least  when  it  is  present  only 
in  a  trifling  degree,  and  it  persists  after  the  protrusion  of  the  eye  has 
subsided. 

2.  Stellwag's  Sign. — This  consists  of  imperfect  power  of  winking  or 
diminished  frequency  in  the  act;  thus,  there  may  be  a  number  of  rapid 
winks,  succeeded  by  a  long  pause  in  which  there  is  no  movement  of  the 
hds,  or  each  time  that  nictitation  occurs,  it  is  not  complete  and  the 
margins  of  the  lids  do  not,  as  in  the  normal  eye,  come  together. 

3.  Dalrymple's  Sign  (Cooper-Swanzy). — This  consists  of  retraction 
of  the  upper  eyelid  so  that  there  is  an  unnatural  degree  of  separation 
between  the  margins  of  the  two  hds.  The  widening  of  the  palpebral 
fissure  produces  the  peculiar  stare  which  is  present  in  the  subjects  of 
exophthalmic  goiter,  and  which  has  been  compared  to  a  similar  appear- 
ance produced  by  the  action  of  cocain. 

4.  Moebius^  Sign. — This  consists  in  an  imperfect  power,  or  in  an 
entire  absence,  of  convergence,  and  may  be  sought  for  in  the  usual 
manner  (see  page  76).  A  decided  pigmentation  of  the  skin  of  the 
eyelids  is  seen  in  some  patients  with  exophthalmic  goiter.  GiiTord 
calls  attention  to  a  symptom  in  exophthalmic  goiter,  namely,  the  diffi- 
culty of  everting  the  upper  eyelid,  which  may  be  present  in  the  early 
stages  of  the  malady. 

Changes  in  the  Cornea. — The  exposure  to  which  the  eye  is  subject 
antl  also  the  paralysis  of  the  nervous  suppl}-  may  cause  drying  of  the 
epithelium  of  the  cornea,  and  ulceration  of  so  violent  a  type  as  to 
produce  destruction  of  the  eye.  New  vessels  may  develop  in  the 
lower  part  of  the  cornea  on  account  of  its  exposure  through  the 
widened  palpebral  fissure.  These  corneal  changes  necessarily  occur  in 
severe  types  of  tiie  disease  where  the  protrusion  of  the  eyeballs  has 
been  considerable. 

Ophthalmoscopic  Changes. — These  are  not  conuiionly  present  to 
any  great  degree  except  in  so  far  as  a  change  in  the  size  of  the  retinal 
vessels  is  concerned.  The  art(!ries  may  be  dilat(>d  ami  a.ssume  a  caliber 
larg(^r  than  normal  and  e(iual  to  that  of  the  veins.  Spontaneous  arte- 
rial pulsation  is  fre(iueiiMy  present  (Becker).  Alterations  in  the  optic 
nerves  and  in  the  general  fundus  jire  not  usually  found,  and  (iiere  are  no 
changes  in  the  eye-grounds  characteristic  of  the  (lis(>ase. 

Nature  of  the  Disease.-  Tiie  cause  of  exophthalmic  goiter  is  not 
known;  but  there  is  Httle  doubt  that  the  syinptoins  of  this  disea-se  de- 


AFFECTIONS  OR  DISEASES  OF  THE  SINUSES 


643 


pend  upon  a  disturbed  function  of  the  thyroid  gland,  whereby  there  is 
excessive  internal  secretion  from  it,  or  entrance  into  the  general  system 
of  more  of  its  active  principle  than  is  normal  (Hare). 

Treatment.— For  the  general  treatment  of  exophthalmic  goiter 
the  student  is  referred  to  the  text-books  on  general  medicine,  surgery, 
and  neurology.  Sympathectomy  has  been  practised  for  the  relief  of 
exophthalmos.  Partial  thyroidectomy  is  usually  performed  and  the 
operation  meets  with  great  success.  If  ulceration  of  the  cornea  occurs 
the  usual  treatment  is  applicable.  To  prevent  exposure  of  the  cornea, 
the  widened  palpebral  fissure  may  be  narrowed  by  the  operation  of 
tarsorrhaphy  (see  Fig.  288). 

Affections  or  Diseases  of  the  Accessory  Sinuses. — In  discuss- 
ing tumors  of  the  orbit,  it  was  noted  that  growths  from  the  frontal 
sinuses,  the  sphenoid  fissure,  the 
ethmoid  cells,  and  the  antrum  may 
encroach  upon  the  orbit.  The 
limits  of  this  book  do  not  permit 
a  full  consideration  of  this  subject, 
for  which  the  student  must  turn  to 
special  treatises.  In  addition  to 
the  morbid  growths  there  remain 
to  be  briefly  considered : 

1.  Disease  of  the  Frontal 
Sinus. — This  is  most  often  a  dis- 
tention of  the  frontal  sinus  bj- 
mucus  (mucocele)  or  pus  (em- 
pyema). Abscess  has  been  at- 
tributed to  postnasal  catarrh, 
syphiUs,  tuberculosis,  and  peri- 
ostitis, and  is  due  to  the  stoppage 
of  the  normal  outlet,  thus  causing 
the  accumulation  of  secretion  until 
the  sinus  becomes  filled,  its  walls 
distended  and  thin,  and  a  tumor 
presents,  usually  at  the  upper  and 
inner  angle  of  the  orbit.  It  may  occur  under  the  influence  of  erysipelas, 
acute  infectious  diseases,  and  epidemic  influenza.  Sensitiveness  on 
pressure  over  the  frontal  bones  and  frontal  headache  or  supra-orbital 
pain  are  common  and  somewhat  characteristic  symptoms,  and  are 
especially  marked  in  acute  frontal  sinusitis.  The  protrusion  may  cause 
displacement  of  the  eyeball  downward  and  outward  and  diplopia,  and 
the  pressure  upon  the  lacrimal  sac,  epiphora.  Coryza  and  purulent 
discharge  from  the  nostril  may  be  present.  According  to  Bull,  if  a 
dense,  hard  swelling  appears  at  the  upper  and  inner  angle  of  the  orbit, 
which  is  slow  in  growth  and  painless,  an  osteom.a  of  the  sinus  is  almost 
certainly  present.  In  rare  instances  the  abscess  in  the  sinus  is  bi- 
lateral. The  x-rays  should  be  used  to  establish  a  diagnosis  between 
osteoma  and  mucocele  of  the  sinus.     A  stereoscopic  radiogram  is  essen- 


FiG.  2G5. — Acute  frontal  and  etlunoid 
sinusitis.  Notice  the  edema  of  the  lid  and 
upper  and  inner  portion  of  the  orbit  (from 
a  patient  in  the  University  Hospital). 


644 


DISEASES    OF    THE    ORBIT 


tial  in  the  study  of  accessory  sinus  disease,  and  careful  transillumination 
of  the  region  is  required  (see  also  C)phthalniodiai)hanoscopy,  j)age  115). 

The  chronic  variety  of  the  tlisease  may  occur  at  any  ap;e  except  be- 
fore the  sixth  year,  because  the  sinus  is  not  much  developed  until  after 
that  time  of  life.  It  is  most  frequent  between  twenty-five  and  thirty. 
and  commoner  in  men  than  in  women. 

The  treatment  consists  in  openinji  the  abscess  and  washing  out  the 
sinus  with  a  bichlorid  solution.  Tiie  incision  may  l)e  made  immedi- 
ately beneath  the  superior  orbital  arch,  directly  outward,  so  that  the 
bony  wall  of  the  sinus,  which  is  here  very  thin,  may  be  easily  opened, 
if  it  has  not  already  perforated.  A.  Knaj^p  prefers  that  the  external 
incision  shall  pass  along  tiic  upper  orbital  border  midway  between  the 
eyebrow  and  the  bonj^  orbital  margin,  and  next  along  the  inner  wall 


Fig.   200. —  Introduction    of    drain-      Fk;.   207 
aKe-tube    after    evacuation  of    ab.sce.s.s 
caused   by  ethnioiditis.      (A  patient  in 
the  Philadelphia  Polyclinic  Ho.spital.) 


-Ethnioiditi.'i   (from  a  patient   in  the 
University  Hospital). 


and  side  of  the  nose  lo  the  floor  of  tlie  orbit.  This  is  better,  in  his 
opinion,  than  the  Killian  incision  through  the  ej'ebrow.  After  the 
wall  of  the  sinus  has  been  perforated  the  contents  of  the  cavity  should 
be  carefully  removed;  often  polypoid  growths  are  present.  The 
communication  l)etwe(Mi  tiie  sinus  and  the  no.se  should  then  be 
re-estabhshed,  and  a  drainage-tube  pjissed  from  the  orl)it,  through  tiie 
opening,  into  the  nose,  or  a  gauze  drain  may  be  pas.se(l  from  without 
into  the  sinus  at  its  na.sal  angle  (Knapp). 

2.  Disease  of  the  Ethmoid.  .\  common  disease  of  the  ethmoid 
cells  is  caused  by  a  retention  of  secretion  in  them— that  is,  adopting 
H.  Knapp's  phrasi^ology,  a  ntcntlon-nisl  develops.  In  tliese  eireum- 
Btances  the  growth  ajjpears  at  the  upjier  and  inner  angle  of  tlie  orbit, 
above  and  behind  the  internal  (•anlliai  ligament,  and  displ.Mces  tlie(\ve- 


AFFECTIONS   OR  DISEASES   OF  THE   SINUSES 


645 


ball  downward  and  outward.  It  may  not  be  possible  to  differentiate 
this  mucocele  from  an  exostosis  until  an  exploratory  incision  is  made. 
With  ethmoiditis  there  may  also  be  tumefaction,  especially  of  the  inner 
third  of  the  lid,  imperfect  movement  of  the  eyeball  with  diplopia,  severe 
neuralgic  pain,  and  profuse  lacrimation.  The  last-named  symptom 
may  cause  the  affection  to  be  mistaken  for  dacryocystitis.  In  puru- 
lent disease  of  the  ethmoid  cells  the  natural  escape  for  the  pus  is  into 
the  nasal  cavity,  where  it  can  be  seen  beneath  the  middle  turbinated 
body,  or  between  this  structure  and  the  septa;  but  this  is  by  no 
means  its  invariable  course.  In  a  large  number  of  cases  pus  escapes 
through  the  os  planum  into  the  orbital  cavity,  giving  rise  to  exoph- 
thalmos and  orbital  abscess.  The  purulent  collection  may  be  evacu- 
ated by  a  free  incision,  so  placed  as  to  expose  the  os  planum  of  the 
ethmoid.  After  all  necrotic  and  carious  tissue  is  removed,  an  opening 
should  be  forced  into  the  nose.     Through  it  a  drainage-tube  should 


Fig.  268. — Purulent  disease  of  ethmoid  and  frontal  sinu>,    with   fistulous  opening  at 
inner  angle  of  orbit  (from  a  patient  in  the  University  Hospital). 

be  passed,  by  means  of  which  the  cavities  can  be  frequently  cleansed 
with  a  bichlorid  or  other  antiseptic  solution.  Often,  after  partial  or 
complete  removal  of  the  middle  turbinate  bone,  the  approach  can  be 
through  the  nose  and  drainage,  aided  by  suction,  secured  in  this 
manner.  Many  other  procedures  are  available  in  the  surgical  treat- 
ment of  ethmoiditis  for  the  description  of  which  the  student  should 
consult  works  on  paranasal  sinus  surgery.  Among  these  H.  P.  Mosher's 
operation  is  particularly  valuable. 

Fistula  of  the  orbit,  presenting  above  the  internal  canthal  ligament, 
may  be  due  to  disease  of  the  frontal  sinus  or  of  the  ethmoid,  and  par- 
ticularly to  disease  of  the  lacrimal  division  of  the  anterior  ethmoid 
cells.  Cases  of  this  character  are  often  mistaken  for  lacrimal  disease, 
and,  in  fact,  they  present  some  of  the  characteristics  of  the  so-called 
prelacrimal  sac  abscess.  A  cure  may  be  effected  by  forcing  with  a 
strong  probe,  as  Gruening  suggested,  an  opening  through  the  base  of 
the  fistula  into  the  nasal  cavity,  thus  facilitating  drainage  through 
the  nose,  or,  better,  by  free  exploration  of  the  affected  sinuses  by  means 
of  a  Killian  or  Knapp  procedure. 


646 


DISEASES    OF    THE    ORBIT 


3.  Disease  of  the  Sphenoid  Sinus. — Kinpyema  of  the  sphenoid 
sinus  mu}'  exist  ulouc,  ur  uiore  often  in  association  with  suppuration 
in  the  ethmoid  cells,  and  may  appear  in  an  acute  or  chronic  form,  A 
diap;nosis  can  often  be  made  by  catheterization  of  the  sinus.  It  is  of 
particular  ophthalmologic  interest  on  account  of  the  intimate  relation 
between  the  walls  of  the  sphenoid  cavity  and  the  optic  nerve  (the  optic 
nerve  may  even  be  free  in  the  sphenoid  sinus  [Onodi]),  and  an  almost 
necessary  symptom  is  some  form  of  optic  neuritis,  either  retrobulbar 
or  localized  in  the  nerve-head  itself.  Optic-nerve  disease  should  al- 
ways induce  the  surgeon  to  take  the  sphenoid  and  ethmoid  sinus  into 
serious  account  (see  also  page  647). 

In  any  case  of  suspected  sinus  disease  a  stereoscopic  x-ray  plate  should 
be  prepared;  this  frequently  will  give  accurate  information  with  respect 
to  the  size,  condition,  and  the  contents  of  the  accessory  nasal  sinuses. 

Other  diseases  of  this  le- 
gion are  polypi,  osteomas,  and 
hyperostoses. 


Fk;.   2G'.K-  Sari'ouia    of    the    orliit  Fig.   270. — Exophthalmos    from   tumor  of 

and  postnasal  space.      (From  a  patient      antrum    which    involved    the    orbit   (from    a 
under  the  care  Dr.Wni.  Zontmaycr).       patient  in  the  JefTeiaon  Hospital  under  the 

care  of  Dr.  J.  Chalmers  DaCosta). 

4.  Disease  of  the  Antrum. — Empyema  of  the  antrum  is  not  an 
uncommon  affection,  and  although  it  does  not  belong  to  the  domain  of 
ophthuhnology,  it  is  sometimes  accompanied  by  marked  ocular  signs. 
In  addition  to  tlic  })ain  located  in  the  clicck,  frc(iucntly  periodic  in  ciiar- 
acter,  together  witii  tiie  escape  of  i)us  from  the  antrum,  there  may  be  a 
marked  edema  of  the  Hds,  which,  if  the  discjise  is  of  lon^  stanihng, 
assumes  a  positively  l)rawny  consistency.  Edema  of  (lie  lids  may 
develop  when  only  a  lew  drops  of  pus  are  present  in  the  cavity  ol  the 
antrum  (W.  Freeman).  Tlieic  may  also  be  chemosis  of  the  con- 
junctiva and  some  edema  of  the  optic  nerve  and  overlilling  of  th(» 


AFFECTIONS  OR  DISEASES  OF  THE  SINUSES  647 

retinal  veins.  A  persistent  edema  of  the  eyelids  not  otherwise  ex- 
plained should  direct  the  surgeon's  attention  to  the  antral  cavity.  A 
certain  number  of  cases  of  lacrimal  disease,  for  example,  ordinary 
forms  of  dacrj'ocystitis  are  connected  with  antral  affections. 

Growths  in  the  antrum — sarcoma,  fibroma,  and  polypi — may  in- 
volve the  orbit  and  produce  exophthalmos,  or  more  often  displacement 
of  the  ej'eball  upward  and  outward. 

The  Ocular  Complications  of  Diseases  of  the  Nasal  Accessory 
Sinuses. — The  relation  of  diseases  of  the  nasal  accessory  sinuses  to 
diseases  of  the  eye  has  been  referred  to  in  preceding  pages  in  the  de- 
scription of  various  ocular  lesions,  notably  those  which  occur  in  the 
optic  nerve,  but  for  convenience  of  reference  thej^  are  redescribed  in  the 
following  paragraphs: 

(1)  Lids  and  Conjunctiva. — Edema  of  the  hd  is  a  common  symptom  of 
frontal,  antral  and  ethmoidal  sinus  disease,  either  the  ordinary  variety,  or 
else  a  recurring  painful  form,  fugitive  in  character  and  associated  with 
violent  headache.  Watering  of  the  eye,  conjunctival  congestion,  dis- 
tinct catarrhal  conjunctivitis,  and  deep-seated  scleral  congestions, 
sometimes  fugacious,  and  often  accompanied  by  intense  headache, 
ocular  pain  and  shght  edema  of  the  corneal  epitheUum,  have  been 
noted  as  frequent  symptoms  of  sinusitis,  especially  in  its  acute  or  early 
stages. 

(2)  The  Cornea  and  Uveal  Tract. — Keratitis,  corneal  ulcers,  iritis, 
uveitis,  choroiditis,  and  vitreous  opacities  may  be  due  to  sinus  disease. 
A  special  form  of  c.ychtis  with  vitreous  opacities,  which  seems  to  be 
due  to  nasal  accessory  sinus  disease,  is  described  b}-  Kuhnt.  (See 
also  page  352.) 

(3)  Retina  and  Optic  Nerve. — The  most  important  group  of  ocular 
comphcations  of  paranasal  sinus  disease  are  those  in  which  there  is 
sinusitis  without  external  signs  of  orbital  inflammation,  but  in  which 
there  are  optic  neuritis,  neuroretinitis,  retinal  thrombosis,  and  phlebi- 
tis, or  in  which,  without  marked  ophthalmoscopic  changes,  there  is  a 
central  scotoma.  In  some  cases  a  typical  acute  retrobulbar  neuritis 
arises, with  all  of  the  symptoms  which  have  been  detailed  on  page  537, 
while  in  others  the  retrobulbar  neuritis  manifests  its  presence  by  a 
relative  central  scotoma,  with  intact  outhnes  of  the  visual  field;  later 
the  scotoma  becomes  absolute  and  the  field  of  vision  contracts.  The 
scotoma  may  be  unilateral,  the  more  usual  condition,  or  bilateral,  and 
most  frequently  depends  upon  disease  of  the  posterior  ethmoidal  cells 
or  of  the  sphenoid  sinus.  Occasionally  the  scotoma  assumes  a  circular 
or  annular  shape.  The  investigations  of  Onodi  have  shown  that  the 
optic  nerve  often  is  in  close  relation  with  these  posterior  ethmoidal 
cells,  and  that  the  thinness  of  the  intervening  wall  renders  involvement 
easy,  even  easier,  it  is  probable,  than  in  the  case  of  the  sphenoid,  which 
anatomically  may  come  in  close  relationship  with  the  nerve  and  form 
the  inner  wall,  or  the  lower  and  inner  wall,  of  the  optic  canal.  Ac- 
cording to  Birch-Hirschfeld,  the  nerve  lesions  consist  in  edema,  swelUng 
and  prohferation  of  the  gha  cells,  and  destruction  of  the  nerve-fibers. 


648  DISEASES    OF    THE    ORBIT 

These  he  attributes  to  venous  stasis  and  also  to  toxic  agencies.  Com- 
pression of  the  optic  nerve  in  the  canal,  or  perineuritis  (Hajek)  and 
extension  of  disease  throufjli  the  intimately  related  soft  tissues  of 
the  sinuses,  orbit  and  optic  canal  (Gradlc)  have  Ix-en  advanced  as 
factors  in  the  production  of  central  scotomas,  Bordley  concludes 
that  their  development  depends  upon  a  dual  cause — mechanical  pres- 
sure and  toxemia  of  the  papillomacular  bundle  either  from  stasis  or 
extension.  In  a  certain  number  of  cases  the  ophthalmoscope  reveals 
the  usual  picture  of  optic  neuritis,  or  papillitis,  with  central  scotoma, 
especially,  as  in  a  case  recorded  by  A.  Knapp,  if  the  anterior  ethmoidal 
cells  are  infected,  and  the  author  has  seen  elaborate  optic  neuritis 
followed  by  optic  nerve  atrophy,  with  extensive  disease  of  the  ethmoid, 
frontal,  and  sphenoid  sinus,  and  sphenoid-sinus  disease  in  whidi  the 
scotoma  assumed  the  form  of  the  so-called  hemiopic  paracentral  sco- 
toma. The  visual  fields  in  disease  of  the. sphenoid  sinus  may  exhibit 
alterations  analogous  to  those  in  affections  of  the  pituitary  body,  for 
example,  bitemporal  hemianopsia.  If  the  cause  of  these  optic  nerve 
complications  is  not  recognized  and  speedily  removed,  eitiier  l)y  suit- 
able intranasal  drainage,  with  or  without  operation,  bhndne.ss  from 
optic-nerve  atrophy  is  Hkely  to  result.  An  important  symptom  of 
posterior  accessory  sinus  disease,  described  by  J.  Van  der  Hoeve,  is 
enlarqe merit  of  the  blind-sjwt  for  white  and  colors.  This  observation 
has  been  confirmed  by  de  Kleijn,  the  author,  and  a  number  of  others 
who  have  investigated  the  subject.  The  enlargement  of  the  l)lind-sj)Ot 
is  attributed  by  Van  der  Hoeve  to  involvement  of  the  peripapillary 
bundle,  which  may  be  the  first  portion  affected  in  retro])ulbar  neuritis. 
If  no  other  cause  for  such  increase  in  the  size  of  the  blind-spot  can 
be  found,  Van  der  Hoeve  considers  it  to  be  a  sj-mptom  which  justifies 
operation  on  the  affected  sinus.  Bordley  found  among  102  patients 
with  disease  of  the  posterior  ethmoid  cells  and  of  the  sphenoid  eidarge- 
ment  of  the  blind-spot  in  31  per  cent,  of  tlie  cases.  This  cnlaigciiicnt 
he  found  more  freciucntiy  asstjciated  with  acute  siiuisitis  than  with 
subacute  and  chronic  forms  of  the  disease. 

(4)  Orbit  and  Lacrimal  Region. — A  mucocele  of  the  ethmoid  or 
frontal  sinus  may  cause  mechanical  displaccmcMit  of  the  orbital  coti- 
tents  and  ('xoi)hthalmos,  and  Birch-Ilirschfeld's  investigations  have 
shown  that  nearly  t)0  per  cent,  of  the  cases  of  orbital  intlammation 
which  he  has  analyzed  were  due  to  accessory  sinus  inflanmiation.  The 
infection  may  cause  a  periostitis  over  the  Hoor  of  the  frontal  sinus  (»r 
over  the  os  planum,  and  biingaboul cxophthahnos.  This  ma>'  disappear 
as  the  result  of  I  real  inent ,  or  a  .subpcrio^ttdl  dhsccss  wiay  develop,  which 
renuiins  encapsulated,  or  which,  by  extension,  may  perforatt*  the  skin 
of  the  eyehd,  leaving  an  orbital  jislula.  Such  periosteal  orbital  .ab- 
scesses an;  frequent  in  children,  the  infection  IxMiig  transmitted  b\  the 
ethmoid  lal>yrinth  (,\.  Knapp).  Heber  concluded  from  his  studies  that 
infection  may  reach  the  orbit  in)  by  (hiccl  continuity.  (It)  by  w;iy  of 
the  venous  cii-cul:il  inn,  and  (r)  \>y  \\  ny  nl'  the  lymphatics.  'I'he  l.-ist- 
n.'uned  route  has  not   been  j)()sil  ixcly  (lenitinst  rated. 


\ 
I 


INJURIES    TO    THE    ORBIT  649 

Finally,  there  may  be  involvement  of  the  orbital  structures  them- 
selves, resulting  in  cellulitis  or  abscess,  either  with  or  without  optic 
nerve  inflammation.  Extension  of  antral  disease  into  the  orbit  is  less 
common  and  rarety  occurs,  according  to  A.  Knapp,  except  through  the 
intermediation  of  the  ethmoidal  cells,  but  both  with  antral  and  with 
ethmoidal  infection  the  symptoms  of  dacryocystitis  may  appear,  and 
not  infrequently  the  mistake  is  made  of  treating  as  a  dacryocystitis  a 
manifestation  of  sinusitis. 

Other  compHcations  which  have  been  recorded  are  glaucoma  and 
detachment  of  the  retina.  The  former  affection  does  not  occur  from 
sinus  disease  unless  the  eye  is  predisposed  to  increased  intra-ocular  ten- 
sion. Intense  neuralgia,  both  ciliary  and  postocular,  stubborn  asthen- 
opia, and  contraction  of  the  visual  field  have  been  attributed  to  the 
same  cause,  dependent,  according  to  Kuhnt,  on  absorptions  of  toxins 
from  the  purulent  processes  in  the  sinuses. 

Palsy  of  exterior  ocular  muscles,  notably  of  the  superior  oblique,  may 
be  caused  by  sinus  disease.  The  author  has  observed  isolated  palsy  of 
the  internus  due  to  ethmoiditis,  and  certain  exterior  ocular  muscle 
palsies  formerly  attributed  to  rheumatism  are  doubtless  due  to  sinusitis. 
Evidently  in  the  presence  of  any  of  these  conditions,  notably  persis- 
tent or  recurring  edema  of  the  hds,  fugitive  episcleral  congestion,  retro- 
bulbar neuritis,  both  acute  and  chronic,  optic  neuritis,  unexplained 
failure  of  vision  with  central  scotomas,  and  stubborn  ciliary  neuralgia 
with  persistent  asthenopia,  expert  examination  of  the  sinuses  is  de- 
manded, not  only  with  all  of  the  means  at  the  disposal  of  rhinologists, 
but  notably  with  the  aid  of  the  x-rays,  and,  in  some  cases,  even  if  the 
results  of  ordinary  examination  are  negative,  especially  in  the  pres- 
ence of  the  optic  nerve  complications,  exploratory  orbital  incisions 
and  investigation  of  the  sinuses  through  them  are  justified.  The 
diagnostic  value  of  Van  der  Hoeve's  scotoma  has  been  explained  (see 
page  648). 

Although  the  ocular  manifestations  of  sinus  disease  are  often 
marked,  it  should  be  remembered,  as  Sattler  points  out,  that  excessive 
dilatation  of  the  pneumatic  sinuses  of  the  skull  may  pursue  an  entirely 
latent  course  and  cause  no  very  decided  eye  symptoms. 

Injuries  to  the  Orbit. — These  include  fracture  of  its  bony  walls, 
penetrating  wounds,  the  lodgment  of  foreign  bodies,  and  contusions. 
The  effects  of  an  injury  of  the  orbit  depend  very  much  upon  the  char- 
acter of  the  wound  and  the  missile  which  has  produced  it.  The  injury 
may  lead  to  a  phlegmonous  inflammation,  to  hemorrhage  within  the  tis- 
sues, and  to  loss  of  sight  because  of  rupture  of  the  eyeball  or  injury  of 
the  optic  nerve.  The  development  of  optic  nerve  atrophy  after  injury, 
evident  to  the  ophthalmoscope,  may  be  delayed  for  several  weeks. 
There  are  Hkely  to  be,  according  to  the  circumstances,  exophthalmos, 
displacement  of  the  eyeball,  and  diplopia.  In  warfare,  as  exempHfied 
during  the  recent  war,  orbital  injuries  from  bullets,  fragments  of  shrap- 
nel are  common  and  cause  various  degrees  of  damage — fracture  of  the 
walls,  severance  of  the  optic  nerve,  gross  concussion  of  the  eye  or  its 


650  DISEASES    OF    THE    ORBIT 

rupture  or  disintegration.  Fragments  of  metal  may  penetrate  the 
globe,  pass  through  and  be  buried  in  the  surrounding  orbital  tissues. 
So,  too,  bullets  may  enter  the  orbit  and  lodge  in  the  adjacent  sinuses 
or  in  the  cranial  cavitj'.  A  comphcation  of  many  of  these  orbital 
injuries  on  account  of  the  exophthalmos  and  injury  of  the  or- 
bital nerves  may  be  neuroparalytic  keratitis  (page  283).  Other 
complications  are  hemorrhage  which  if  excessive,  increases  the 
proptosis,  orbital  cellulitis  and  gas  bacillus  infection  {bcu:illus  aerogenes 
capsulatus).  Air  may  escape  into  the  cellular  tissues  of  the  orbit  and 
produce  emphysema  which  is  detected  by  a  crackUng  sound  when  the 
eye  is  pressed  backward. 

Treatment. — After  a  penetrating  wound  a  careful  search  for  a 
foreign  body  should  be  made  and  if  reasonably  accessible  it  should  be 
removed  either  through  the  channel  of  entrance  or  through  a  new  passage 
(see  below) .  In  a  number  of  instances  extraordinary  foreign  bodies  have 
been  found  in  the  orbit,  and,  curiously  enough,  very  remarkable  toleration 
of  the  presence  of  such  bodies.  If  the  penetrating  wound  has  cut  off 
the  attachment  of  one  of  the  ocular  muscles  and  the  patient  is  seen 
soon  enough,  an  endeavor  should  be  made  to  suture  the  detached  ends. 
In  cases  of  excessive  hemorrhage  within  the  orbit  it  may  be  necessary 
to  make  an  incision  and  remove  the  escaped  blood.  x-Ray  examina- 
tion naturally  furnishes  a  means  of  detecting  foreign  bodies  in  the  orbit, 
the  position  and  character  of  the  fracture  and  whether  the  foreign 
body  remains  within  the  orbit  or  has  passed  beyond  its  bounds.  A 
foreign  body,  if  unassociated  with  infection  and  not  easily  removed, 
had  better  be  allowed  to  remain  than  to  make  injudicious  exploration. 
In  some  cases  of  deeply  seated  foreign  body  resection  of  the  orbital 
.  wall  has  been  the  means  of  securing  it.  Removal  of  the  foreign  body 
in  the  presence  of  suppurative  orbital  cellulitis  followed  by  free  drain- 
age and  in  severe  cases  Carrel's  tubes,  is  reconuiiended  by  Greenwood. 
Metalhc  foreign  bodies  can  sometimes  be  removed  with  a  magnet. 

Hemorrhage  into  the  Orbit. — In  addition  to  the  orbital  hemor- 
rhages caused  b}'  injury  which  have  been  referred  to,  or  which 
may  follow  operation;  spontaneous  hemorrhages  may  occur.  They 
have  been  observed  in  children  with  scurvy,  as  the  result  of  arte- 
riosclerosis in  old  people,  in  whooping-cough  and  henu)phiUa. 
Cysts  following  hemorrliage  iiave  been  clescribed.  Arteriosclerotic 
orbital  hemorrhage  maj'  manifest  itself  in  a  recurring  form,  antl  the 
hemorrhage  occasioned  by  scorbutus  is  often  associated  with  pro- 
nounced ecchymosis  of  the  lids  and  sui)conjunctival  hemorrhage. 

Dislocation  of  the  Hyeball. — The  cveball  may  l>e  dislocated  l>e- 
tw(K!n  the  lids,  which  are  contracted  behind  it.  It  is  a  rare  form  of 
injury.  An  eyeball  may  pur|)osely  be  prietl  from  its  socket  by  means 
of  a  thumb  thrust  into  the  orbit  from  the  outer  side.  Luxation  of  the 
globe  as  a  self-inflicted  injury  has  becui  observed  among  the  insane. 
The  result  of  such  an  accident  may  be  laceration  of  the  optic  nerve  an«l 
destruction  of  sight.  In  other  instances  the  vision  has  remained  un- 
alTected.     In  certain  cases  of  exopiithalmos  it  is  possible  to  produce 


I 


EXOPHTHALMOS 


651 


this  dislocation  by  pressure  upon  the  globe  with  the  thumbs,  the  re- 
laxed muscles  permitting  the  eyeball  to  protrude  between  the  lids. 
The  eye  should  be  replaced  and  bandaged;  it  may  be  necessary  to 
divide  the  external  commissure. 

Enophthalmos,  or  retraction  of  the  eyeball,  occurs  both  as  an 
idiopathic  and  a  traumatic  affection.  Enophthalmos  the  result  of  ex- 
hausting diseases  is  more  apparent  than  real,  but  a  true  sinking  of  the 
globe,  producing  an  appearance  not  unlike  that  caused  by  a  badly 
fitting  artificial  eye  (Nieden),  may  follow  a  traumatism  in  the  neigh- 
borhood of  the  orbit  (Fig.  271).  Enophthalmos,  miosis,  slight  ptosis 
and  unilateral  sweating  have  been  noted  in  babies  after  prolonged  in- 
strumental labor  (Mayou). 

This  retraction  of  the  eyeball  may  immediately  follow  the  injury, 
or  be  delayed  for  days  or  even  months.  According  to  the  conditions 
which  are  present,  it  has  been  ascribed 
to  paralysis  of  Miiller's  orbital  muscle 
from  lesion  of  the  sympathetic  (Schap- 
ringer) ;  to  atrophy  of  the  retrobulbar 
cellular  tissue  caused  by  trophic  nerve 
disturbance  (Beer);  to  fracture  and 
depression  of  the  orbital  bones  with 
cicatricial  adhesion  .  or  contraction; 
and  to  injury  of  Tenon's  capsule  and 
the  check  ligaments  (W.  J.  Shoe- 
maker). It  may  be  associated  with 
palsy  of  the  inferior  oblique  (Fuchs, 
Sachs). 

Exophthalmos  caused  by  paraly- 
sis of  the  ocular  muscles,  tenotomies 
for  the  reUef  of  strabismus.  Graves'  dis- 
ease, orbital  disease,  orbital  growths, 
and  affections  of  the  nasal  accessory 
sinuses  has  been  referred  to.  It  may  also  occur  as  the  result  of  irrita- 
tion of  the  cervical  sympathetic  under  the  influence  of  certain  poisons, 
notably  thyroid  extract  and  paraphenylendiamin,  in  acromegaly, 
myelitis,  and  certain  tumors  of  the  brain,  notably  those  which  are 
situated  in  the  neighborhood  of  the  third  ventricle  and  in  the  middle 
fossa  of  the  skull.     (See  also  Proptosis,  page  92.) 

Intermittent  exophthalmos  is  a  rare  affection,  about  60  cases  being 
on  record.  It  has  been  well  described  in  this  country  by  Posey.  The 
characteristic  symptoms  are  a  more  or  less  rapid,  steadily  forward 
movement  of  one  eye  when  the  head  is  placed  in  a  dependent  position, 
or  when  the  flow  of  blood  from  the  head  to  the  trunk  is  impeded  to  any 
extent.  In  other  circumstances  the  eye  usually  presents  a  normal 
appearance,  or,  on  the  subsidence  of  the  exophthalmos,  there  may  be 
a  shght  enophthalmos.  According  to  Birch-Hirschfeld,  intermittent 
exophthalmos  depends  upon  a  varix  of  the  orbital  veins,  the  origin  of 
which  may  be  congenital,  although  usually  the  venous  stasis  does  not 


Fig.  271.^ — Traumatic  enophthal- 
mos, patient  looking  straight  forward ; 
sunken  appearance,  resembling  a  badly 
fitting  artificial  ej'e,  well  shown. 


652 


DISEASES   OF   THE    ORBIT 


take  place  until  later  in  life,  and  occurs  under  the  influence  of  the 
mechanical  factor?  to  which  roforonco  has  boon  made. 

Contusion  and  Concussion  of  the  Eyeball. — References  to 
some  of  the  effects  of  oontusion  and  concussion  of  the  eyeball  a->*  the 
result  of  the  violent  impact  of  a  l)lunt  object,  for  exami^le  a  fiying  ball  or 
cork,  a  clenched  hand,  etc.,  have  been  made  in  the  descriptions  of 
rupture  of  the  sclera  (page  317),  iridodialysis  (page  345),  concussion 
cataract  (page  441),  rupture  of  the  choroid  and  holes  in  the  macula 
(page    507),   detachment   of  the  retina   (page  492),   and   commotio 


Via.  272. — Concu-ssioiii'il  fiiii<liis  (from  :i  i)alictit  in  thi>  I'liivorsity  Hospital). 


retinse  (page  50G).  It  may  bo  coii\'oiiioiil  to  suimiiaiizc  in  addition 
to  these  effects  of  concussion  and  contusion  (lioii-  i(>lation  to  the  oyo 
as  .seen  in  wdrfdrc,  paiticulaily  during  the  rocont  war. 

In  general  Icniis  tlic  lesions  arc  caused  (linrth/  hy  a  Mow,  or  siuMeii  forceful 
pressure  on  the  eyehall,  heliind,  from  the  side,  or  taiiK<'iitially ;  or  indincth/,  hy  the 
transmission  of  concussion  or  siiock. 

(.'(jnlact  lesions  are  eau.sed,  for  example,  hy  a  mi.ssile  which  grazes  the  ^lohe 
hut  does  not  rupture  it,  or  l)v  a  fragment  or  jxirtion  of  a  fractured  orl>it:d  w.all  or 
floor  or  roof,  tiirust  liarshly  against  the  eychall. 

('oncussion  lesions  are  caused:  (a)  hy  concussion  !it  a  disl.ince.  for  iiisl;ince, 
violent  dis|)I,'ic('iiiciit  of  all'  !>>•  the  explosion  of  a  shell   t  l.;ini;inne) ;  (l>^  hy  tr.ans- 


CONTUSION  AND  CONCUSSION  OF  EYEBALL        653 

mission  of  concussion  or  shock  through  the  bony  facial  structures  arid,  moreover 
not  only  through  those  near  to  the  eye,  to  wit,  the  malar  bones  and  orbital  margins, 
but  through  the  superior  maxilla  (especially  if  the  missile  passes  through  the 
antrum),  and  the  inferior  maxilla;  and  (c)  by  slight  blows  on  the  anterior  part  of 
the  eye,  the  concussion  being  transmitted  through  the  transparent  media  to  the 
posterior  pole  (Lagrange). 

The  lesions  as  usually  described  may  be  summarized  thus:  (1)  Lesions  by 
concussion,  (2)  lesions  bj-  impact,  and  (3)  combined  lesions,  i.e.,  both  by  concussion 
and  impact  the  lesions  being  in  front  of  or  adjacent  to  the  spot  of  contact,  and  also 
immediately  opposite  to  the  site  of  impact ;  or,  in  another  sense,  as  lesions  which  are 
not  associated  with  and  lesions  which  are  associated  with  fracture  or  perforation  of 
the  orbit  (passage  of  a  missile  through  it). 

The  character  and  degree  of  the  visual  depreciation  depends  upon  the  extent, 
situation  and  age  of  the  lesions. 

The  visual  field  changes  depend  upon  the  location  of  the  lesion  and  its  depth 
and  character.  Sir  W.  T.  Lister  states  that  "lesions  above  or  below  the  horizontal 
plane  caused  a  defect  in  the  field  out  of  proportion  to  the  local  disturbance,  a  "dis- 
tribution defect"  being  found  in  addition  to  the  local  defect  due  to  the  lesions. 
This  is  due  to  the  fact  that  not  onh-  was  the  spot  struck  damaged,  but  also  ner\-e 
fibers  in  the  immediate  vicinity  which  were  pa.ssing  on  to  a  more  peripheral  portion 
of  the  retina.  This  distribution  defect  is  fan-shaped,  the  expanded  portion  being 
peripheral  and  the  nearer  the  lesion  is  to  the  di.sk,  the  greater  is  the  bhnd  sector, 
and  vice  versa.  "When  the  lesion  occurs  in  the  horizontal  plane  no  "distribu- 
tion defect"  is  found,  as  the  fibers  supplying  the  retina  in  the  horizontal  line 
arch  around  from  the  disk  to  their  destination,  and  therefore  these  lesions  can  only 
involve  the  ner\-e  fibers  at  their  terminations.  Scotomas  of  various  shapes  may 
interpret  the  macular  and  paramacular  alterations. 

Marked  reduction  of  intra-ocular  tension  (hypoiony)  is  common  in  many  of 
these  cases.  The  statement  that  lowered  eyeball  tension  is  an  important  sign  of 
perforating  scleral  wounds,  and  especially  of  diagnostic  import  when,  for  example, 
a  small  penetrating  wound  of  the  sclera  is  covered  with  tumid,  and  it  may  be 
swollen,  conjunctiva,  must  not  be  taken  unreservedly  in  view  of  the  many  observa- 
tions in  this  war.  Lesions  of  the  inner  eye  by  concussion  from  a  distance,  by 
concussion  transmitted  through  the  bony  facial  structures  and  following  blows  on 
the  point  of  the  eye,  by  preference  are  located  in  the  macula  and  paramacular  area; 
impact  lesions  are  equatorial  and  always  adjacent  to  the  site  of  contact ;  a  con- 
tact lesion  may  spread  toward  the  center;  posterior  pole  and  equatorial  contact 
lesions  may  approach  and  join  each  other;  missiles  traversing  posterior  to  the 
bulbus  and  radiating  fractures  of  the  orbital  vault  are  responsible  for  most  of  the 
direct  optic  nerve  injuries.  Whether  it  is  safe  to  say  that  impact  lesions  are 
always,  or  almost  always,  retinochoroidal  and  concussion  lesions  choroidal,  as 
Lagrange  contends,  it  would  seem  is  not  settled. 

Unquestionably  the  difference  between  concussion  changes  of  the  fundus 
encountered  in  civil  and  military  practice  depends,  as  Lister  points  out,  in  greatest 
measure  upon  the  fact  that  in  ordinary  circumstances  the  blow  is  delivered  by  a 
comparatively  slow-moving  object,  while  in  warfare  the  missile  passing  through  the 
orbit  m.oves  rapidlj'. 


CHAPTER  XXII 
OPERATIONS 

Ophthalmic  surgeons,  in  so  far  as  the  preparation  of  their  hands, 
gowns,  operating-rooms,  and  surroundings  is  concerned,  naturally 
follow  the  strict  rules  of  modern  surgery. 

Preparation  of  the  Skin  of  the  Region  of  Operation. — The 
skin  should  be  treated  first  with  soap  and  water,  then  with  alcohol,  and 
finally  with  corrosive  sublimate  (1:2000).  These  irritating  sub- 
stances must  not  enter  the  conjunctival  sac,  but  the  face,  surface  of  the 
closed  lids,  eyebrows,  brow,  and  scalp  should  be  thus  prepared.  The 
cihary  margins  should  be  carefully  cleansed  with  soap  and  water,  fol- 
lowed by  bichlorid  of  mercury  (1  :5000).  The  parts  should  be  kept 
covered  with  a  compress  of  lint  soaked  in  the  bichlorid  solution  until 
the  operation  begins.  In  place  of  this  preparation  the  eyelids  may  be 
cleansed  with  benzine  on  a  cotton  swab,  to  be  followed  by  a  thorough 
washing  with  fluid  neutral  soap.     This  is  the  practice  in  Fuchs'  cUnic. 

The  preparation  of  the  conjunctival  sac  depends  upon  the  nature  of 
the  operation  (see  page  727). 

Preparation  of  the  Instruments. — All  coarse  instruments,  such 
as  hooks,  scissors,  etc.,  should  be  boiled  for  at  least  ten  minutes  in  the 
usual  manner  in  a  sterilizer. 

Sharp  instruments — cataract  knives,  keratomes,  cj^stotomes,  etc. —  *■ 

must  be  cleansed  with  great  caution  lest  damage  be  done  to  their  ., 

edges.     First  the  edge  of  the  instrument  is  inspected  with  a  magnifying  \ 

glass,  next  the  instrument,  wrapped  in  cotton,  is  put  into  boihng  water  • 

for  five  minutes,  and  from  this  transferred  to  a  dish  containing  abso- 
lute alcohol,  carefully  wiped  with  the  cotton  saturated  in  the  alcohol, 
and  finally  placed  in  a  tray  of  sterile  water.  Just  Ijcfore  the  operation 
begins,  it  is  removed  from  the  water,  thoroughh'  dried,  laid  upon  a 
layer  of  sterile  gauze,  and  covered  with  another  layer  of  the  same  ' 

material.  As  boiling  is  likely  to  spoil  the  edges  of  sharp  instruments. 
Slroschein  beheves  that  it  is  sufficient  to  rub  them  with  cot  ton- wool 
soaked  in  a  mixture  of  equal  parts  of  alcohol  and  ether,  and  subse- 
quently to  wash  them  in  a  5  per  cent,  solution  of  carbolic  aciil. 

Dressings. — These  must  be  modified  according  to  circumstances.  1 

In  plastic  operations  about  the  lids  the  ordinary  dressings  that  is  to 
say,  steam-  or  heat-sterilized  gauze — may  l)e  api)lie(l,  held  in  place  with 
a  sterile  gauze  roller  (see  also  page  t)74).     Iodoform  gauze  is  occa-  i 

sionally    useful    in    packing    the    orbit   after  evisceration,   although  I 

ordinary  sterile  gauze  yields  equally  satisfactory  results.  'i 

If  a  wet  dressing  is  desired,  the  fabric  may  be  soaked  in  bichlorid  <; 

solution  (1  loOOO),  saturated  boric  acid  solution,  t)r  in  a  physiologic  salt 

(i.-.i 


GENERAL    ANESTHESIA 


655 


solution  which  has  been  sterihzed  by  boihng,  the  last  preparation  being 
especially  valuable  if  skin-grafting  has  been  employed.  Bits  of  sterile 
gauze  or  tightly  packed  pledgets  of  cotton  wrung  out  from  a  1  :  5000 


Fig.  273. — Figure-of-S  of  one  eye. 


Fig.  274. — Figure-of-8  of  both  eyes. 


bichlorid  solution  are  useful  for  removing  blood,  etc.,  from  the  area  of 
operation.  The  various  dressings  used  after  cataract  extraction,  iri- 
dectomy, etc.,  will  be  described  in  another  section  (see  page  732). 

Either  a  single  or  double  gauze 
bandage  may  be  employed,  or  a  modi- 
fication of  Liebreich's  bandage. 

Sutures. — These  may  be  of  catgut, 
horsehair  or  of  silk.  In  the  author's 
opinion  silk  is  alwaj's  the  preferable 
material,  and  black  silk  is  more  satis- 
factory'' on  account  of  the  ease  with  which 
it  can  be  detected  when  the  time  comes 
for  its  removal. 

General  Anesthesia. — The  indica- 
tions for  general  anesthesia  in  ophthal- 
mic surgery  are  limited.  In  children  or 
in  nervous  adults,  and  for  enucleations, 
eviscerations,  etc.,  blepharoplastic  opera- 
tions, occasionally  in  advancements  of 
the  muscles,  and  in  most  cases  of  acute 
glaucoma,  general  anesthesia  is  necessary. 
The  surgeon  must  decide  between  ether 
and  chloroform. 

The  author  prefers  to  use  the  former,  as  it  is  safer  than  chloro- 
form or  the  mixture  of  chloroform,  ether,  and  alcohol.  Bromid  of 
ethyl  has  been  recommended.  The  author  has  not  been  favorably  im- 
pressed with  this  anesthetic.  The  practice  of  beginning  an  anesthesia 
with  nitrous  oxid,  which  is  to  be  continued  with  ether  or  chloroform, 


Fig.  275.- 


-Modified  Liebreich's 
bandage. 


656 


OPERATIONS 


obviously  possesses  many  advantages.  Primary  inhalation  of  ethyl- 
C'hlorid  is  commended  by  some  surgeons.  With  scopolamin-morphin 
anesthesia,  sometimes  employed  in  surgical  operations,  the  author  has 
had  no  experience,  nor  has  he  had  experience  with  intravenous  injec- 
tions of  ether.  The  administration  of  ether  is  greatly  facilitated  by 
means  of  various  forms  of  inhalers  and  vaporizing  apparatus. 

Local   Anesthesia   and  Analgesia. —  1.   Cocain, — Hjdrochlorid 
of  cocain  is  usually  ciiiploycd  in  a  2  or  4  per  cent,  solution.     A  10  per 
cent,  solution  has  been  advised  in  the  ojieration  (^f  curetting  lupus  and 
similar  growths.     General  anesthesia  is  more  satisfactory.     Cocain 
causes  drjnng  and  roughening  of  the  corneal  epitheUum.     This  may  be 
partly  avoided  by  keeping  the  lids  closed  after  each  instillation.     The 
drug  should  not  be  used  too  freel}'.  or  it  may.  according  to  Mellinger, 
prevent    closure  of  the   corneal   wound.     Gelatin   disks  impregnated 
with  cocain,  as  reconunendcd  by  some  surgeons,  have  no  advantage 
over  a  solution  of  the  drug.     For  thorough  local  anesthesia  Haab 
recommends  the  application  of  a  thin  layer  of  cocain  in  crystals.     Vari- 
ous fungi  grow  readily  in  solutions  of  this  alkaloid,  and.  indeed,  in 
solutions  of  any  of  the  alkaloids  commonly  used  in  ophthalmic  practice. 
A  number  of  methods  of  sterilization  are  em- 
ployed,   namely,   sterihzation   by  heat,  by  the 
addition  of  an  antiseptic  (a  1:5000  solution  of 
bichlorid  of  mercury,  4  per  cent,  of  boric  acid, 
or  trikresol,   1 :  1000,  as  was  suggested  by  Dr.  E. 
A.  de  Schweinitz,  or  by  the  combination  of  these 
two  methods).     The  best  method,  however,  is 
to  boil  the  solution.     A  number  of  convenient 
flasks    designed    for    this   purpose   are    on   the 
market,  among  the  best  being  those  introduced 
by  Dr.  Stroschein.  of  Wurzburg  (since  improved 
and  modified  by  Siiller-Huguenin).  ami  the  one 
devised  l)y  Llewellyn,  of  Philadelphia  (Fig.  27()). 
The  solution  is  placed  in  the  latter  flask  and  boiled.     After  the  li(iuiil 
is  cool  and  ready  for  use,  the  warmth  of  the  liaiid  causes  the  fluid  to 
drop  from  the  end  of  the  pipet.      If  it  is  desinMl  to  |)reserv(.  the  solution 
after  boiling,  a  })ortion  of  one  of  the  antiseptic  sul)stances  previously 
mentioned  may  be  added.     Boiling  is  apt    to  (h coniijose  cocain  ami 
destroy  its  anesthetic  value. 

2.  Novocain,  although  inferior  to  cocain  as  an  ocular  anesthetic,  has 
certain  advantages  in  that  its  solutions  may  i)e  st(>rilized  by  Itoiling 
and  it  is  mucii  less  toxic.  It  may  be  used  in  a  1  or  2  percent.  s()lutii>n. 
and  is  employed  with  advantage  in  infiUration  ain'sliiesia.  I'or  this 
purpose  it  may  be  combine(l  with  adren.alin. 

'A.  Eucain  may  be  obtain<'<l  in  the  form  of  hy(hdchlorate  ot  encain 
"A,"  whicii  in  2  per  cent,  sohition  is  an  ellicient  ane.sthetic,  l>ul  pii»- 
duces  disagreeable  congestion  of  the  conjunct i\a.  and  in  the  form  of 
hydrochlorate  of  eucain  "  H,  "  which  is  related  to  eucain  "  A,  "  and  also 
to  cocain  -.umI  t  iopaco<'ain.      It   is  not  deconipt»sed  by  boiling,  ainl  in  2 


Fig.    276.— Flask    for 
sterilizing  ooUyria. 


LOCAL    ANESTHESIA    AND    ANALGESIA  657 

per  cent,  solution  is  an  active  anesthetic  which  does  not  dilate  the  pupil 
and  is  said  not  to  cause  clouding  of  the  corneal  epithehum. 

4.  Holocain. — A  2  per  cent,  solution  of  this  drug  causes  anesthesia 
in  from  fifteen  seconds  to  one  minute,  which  lasts  for  about  ten  minutes, 
preceded  by  a  moderate  burning  sensation.  It  is  an  admirable  local 
anesthetic,  and  its  solution  does  not  enlarge  the  pupil,  does  not  affect 
accommodation  nor  increase  intra-ocular  tension,  and  is  said  to  possess 
bactericidal  properties  (Randolph) .  It  is  preferred  by  many  surgeons 
to  cocain  in  operations  on  the  eyeball,  for  example,  cataract  extrac- 
tion. Its  value  as  an  application  to  corneal  ulceration  has  been 
described.  A  mixture  of  cocain  and  holocain  is  also  emploj'ed  and 
possesses  certain  advantages. 

5.  Acoin. — This  drug  is  related  to  caffein  and  theobromin,  and, 
according  to  Randolph's  experiments,  is  an  active  local  anesthetic  in 
unirritated  eyes  in  solutions  of  1:100  and  1:300.  It  has  no  effect 
upon  accommodation,  the  size  of  the  pupil,  and  does  not  increase  intra- 
ocular tension  or  cloud  the  corneal  epithehum.  In  congested  eyes 
even  repeated  instillations  of  acoin  do  not  produce  satisfactory  anes- 
thesia. It  may  be  used  to  prevent  the  pain  of  subconjunctival  injec- 
tions (page  689). 

6.  Stovain. — This  drug  in  4  per  cent,  solution,  dropped  on  the 
conjunctiva,  causes  smarting,  burning,  and  lacrimation,  followed  by 
anesthesia,  which  lasts  for  about  five  minutes.  It  has  little  or  no  in- 
fluence on  the  pupil  and  does  not  cause  paresis  of  accommodation. 
In  aqueous  solution  it  is  not  altered  by  boihng,  which  renders  its 
steriHzation  convenient.  It  has  also  been  used  as  an  injection  into  the 
tissues  to  produce  local  anesthesia.  The  author  has  had  no  experience 
with  the  drug. 

7.  Alypin. — This  sj^nthetic  compound  is  a  glycerin  derivative.  A 
2  per  cent,  solution  instilled  into  the  conjunctival  sac  causes  sHght 
smarting,  some  dilatation  of  the  superficial  vessels,  especially  those 
around  the  cornea,  and  anesthesia,  which  is  evident  in  about  one 
minute  (Stephenson).  It  apparently  does  not  dilate  the  pupil,  and  is 
said  to  have  no  influence  on  accommodation. 

8.  Dionin. — This  is  a  morphin  derivative,  which  produces,  a  few 
seconds  after  its  instillation  into  the  conjunctival  sac,  smarting,  burn- 
ing, stinging,  and  marked  edema  of  the  conjunctiva,  especially  of  that 
of  the  bulbar  expansion.  Occasionalh'  the  lid  participates  in  the 
swelhng,  and  not  rarely  the  ''dionin  reaction"  is  severe.  Soon  the  eye 
estabhshes  immunity,  and  after  a  few  apphcations  on  succeeding 
days  the  reaction  is  Httle  marked  and  sometimes  does  not  take  place. 
Within  twenty  minutes  the  edema  of  the  primary  reaction  subsides 
and  analgesia  appears,  which  may  last  for  several  hours.  The  drug  is  a 
lymphagogue,  an  analgesic,  and  probably  has  some  influence  in  altering 
and  conserving  the  nutrition  of  certain  tissues,  for  example,  the  cornea. 
Its  lymphagogue  action  is  the  important  therapeutic  one.  Its  indica- 
tions have  been  described  with  the  various  diseases,  and  it  is  especially 
valuable  in  the  treatment  of  certain  types  of  ulcerative  and  parenchy- 

42 


658  OPERATIONS 

matous  keratitis,  iridocyclitis,  ami  glaucoma.  The  author  employs 
the  drug  in  a  solution  varyinp;in  strength  from  1  to  5  per  cent.,  according 
to  the  indications,  from  once  to  four  times  per  diem  until  immunity  is 
estabUshed;  the  drug  is  now  discontinued  for  three  days;  at  the  expira- 
tion of  this  time  a  modified  reaction  will  again  usually  appear.  If  it  is 
urgent  that  the  drug  shall  be  contiruied  after  imnmnity  is  estabhshed. 
the  strength  of  the  drug  is  increjised,  but  never  beyond  10  per  cent. 
It  may  also  be  employed  in  salve  or  powder.  It  is  an  exceedingly 
valuable  remedj^;  occasionall}'  it  produces  serious  reaction;  rarely  it 
aggravates  existing  conditions,  especially  if  the  patients  are  the  sub- 
jects of  arteriosclerosis  and  renal  disease.  The  value  of  the  drug  may  be 
enhanced  b}^  preceding  its  application  with  holocain  and  following  it  wit  h 
adrenalin-chlorid.  Dionin,  although  an  analgesic,  is  not  a  local  anes- 
thetic, and  in  that  sense  does  not  belong  to  those  drugs  which  are  used  to 
produce  in^ensitiveness  of  the  tissue  with  which  they  come  in  contact. 

With  peronin,  which  is  related  to  benzol  and  morphin,  and  has  an 
anesthetic  as  well  as  a  miotic  action,  and  which  has  been  ^idvocated 
in  glaucoma,  and  with  yohimbin,  which  is  a  local  anesthetic  and  which 
has  been  investigated  in  tliis  country  by  Claiborne,  the  author  has  had 
no  experience. 

Infiltration  Anesthesia. — In  hd  operations  cocain  solution  (1  to 
2  per  cent.)  or  novocain  solution  may  be  injected  beneath  the  skin 
(holocain  cannot  be  used  for  this  purpose),  but  probably  a  more  efh- 
cacious  and  safer  procedure  is  the  so-called  infiltration  anesthesia  j 

introduced  by  C.  L.  Schleich.     This  consists  of  an  intracutaneous  (not.  j 

subcutaneous)  injection  with  a  hypodermic  sj'ringe,  or  with  one  spe- 
cially devised  for  the  purpose,  of  a  0.2  per  cent,  solution  of  sodium  4 
chlorid,  which  is  reinforced  by  the  addition  of  from  Vfoo  to  ,^50  of  1  per 
cent,  of  cocain.     The  fluid  injected  produces  edema,  and  the  anesth(^sia  ! 
is  strictly  limited  to  the  edematous  area. 

A  mixture  of  beta-eucain  and   cocain  may  be  employed  by  sub-  . 

cutaneous  injections  for  local  anesthesia,  and  very  satisfactory  results 
can  be  produced  with  beta-eucain  and  adrenalin-chlorid.  Arthur  !•'. 
J.  Barker's  solution  is  as  follows: 

Pure  chlorid  of  .sodium 0 .  S      gm. 

Heta-eucain 0.2      gm. 

Adrenalin-chorid 0.001  gm. 

Distilled  w ater 100 .  00    gm. 

The  efficiency  of  this  solution  can  Ix*  still  further  enhani-cd  liy 
adding  cocain.  A  1  i)er  cent,  stdution  of  cocain  to  which  4  minims  (0.24 
c.c.)  of  adrenalin  (1 :  1000)  are  adiled  is  a  useful  mixture  for  local  anes-  _ 

thesia  (Meller).     Pooley  reconunends  the  following  fornmla:    .\lypin.  ■ 

15}^  grains  (1  gm.);  sodium  chlorid,  12  grains  (O.TS  gm.) ;  adrenalin.  10 
minims  (O.C)  c.c.);  distilled  wat<>r,  'A^  2  ounces  (104  c.c.). 

Siegrist's  Method  of  i.ocal  Anesthesia.-  The  fluid  consists  of  a 
1  or  2  per  cent,  solution  of  nororain,  to  which,  after  sterilization,  a  , 

few   drops   of   adrenalin  (1:1000)  are  atlded.      In  enucleation  of  the  j 

eyeball    I  lie    niellio<I    is    MS    follows:   After    the    conjunt't  ival    sac    hjis 


EPILATION    OF    THE    EYELASHES  659 

been  anesthetized  in  the  usual  manner,  with  a  curved  canula-needle 
attached  to  a  glass  syringe  of  2-c.c.  capacity,  two  injections  are  made 
into  the  posterior  part  of  the  orbital  cavity  behind  the  eyeball,  the 
needle  being  inserted  on  the  nasal  and  temporal  sides  below  the  hori- 
zontal line,  so  that  it  shall  not  pass  through  the  muscles.  Four  instead 
of  two  deep  injections  may  be  made,  up,  down,  in  and  out,  0.75  c.c. 
of  the  fluid  being  used  at  each  point.  Because  Seidel  has  found  that 
this  method  does  not  always  create  satisfactory  anesthesia,  he  has 
modified  it  in  that  with  a  straight  needle  he  injects  1  to  2  c.c.  of  the 
novocain-adrenaHn  solution  around  the  cornea,  4  mm.  from  its  border. 
Next  four  deep  injections  are  made,  the  needle  being  inserted  upward, 
downward,  outward,  and  inward  over  the  muscular  insertions  to  a 
point  midway  between  the  optic  nerve  entrance  and  the  optic  foramen. 
Each  injection  should  contain  1  c.c.  of  the  solution.  The  immediate 
results  are  edema  of  the  hds  and  exophthalmos,  which  may  be  reduced 
by  pressure.  Elschnig  produces  local  anesthesia  by  deep  injections  in 
the  neighborhood  of  the  cihary  ganglion.  This  form  of  anesthesia  may 
be  employed  in  ordinary  enucleations,  save  only  that  it  is  not  satis- 
factory in  children  and  nervous  persons,  nor  should  it  be  used  if  the 
eyeball  is  badly  shattered  or  in  a  state  of  panophthalmitis. 

Local  Hemostasis. — For  the  purpose  of  producing  a  hemostatic 
and  astringent  action  the  surgeon  may  employ  various  preparations  of 
the  suprarenal  capsule,  as  originally  suggested  by  Dr.  Bates,  of  New 
York.  The  dried  and  powdered  gland  (1  part  to  10  parts  of  water)  has 
been  used;  other  preparations  are  atrahilin  and  suprarenin.  The  most 
satisfactory  preparation  (containing  the  principle  isolated  by  Taka- 
mine)  is  adrenalin  Qhlorid.  It  is  efficacious  in  a  solution  of  1  :  10,000, 
and  is  active  in  even  weaker  solutions ;  as  dispensed  the  solution  is  of  a 
strength  of  1  :  1000.  This  preparation  is  used  for  controlhng  hemor- 
rhage during  shght  operations  on  the  eye,  for  example,  tenotomies, 
excision  of  pterygia  etc.;  for  temporarily  blancliing  a  congested  con- 
junctiva, and  specially,  if  it  is  desired  to  differentiate  the  types  of 
injection  in  the  different  sets  of  vessels  (see  page  49) ;  as  an  adjuvant  to 
the  physiologic  action  of  certain  remedies,  for  example,  eserin  in  glau- 
coma, atropin  in  iritis,  etc.;  to  enhance  the  value  of  certain  subcutane- 
ous injections  for  the  purpose  of  producing  local  anesthesia  and  con- 
trolling hemorrhage  (see  page  658);  and,  finally,  as  a  therapeutic  agent, 
the  indications  for  which  have  already  been  given. 

OPERATIONS  UPON  THE  EYELIDS 

Epilation  of  the  Eyelashes. — Removal  of  the  lashes  is  performed 

with  forceps  known  as  cilium  forceps  (Fig.  277). 


L 

Fig.  277. — Cilium  forceps. 

The  patient  being  seated  in  good  light,  the  operator  with  the  fingers  of  one 
hand  puts  the  Hd  upon  a  stretch,  at  the  same  time  sUghtly  everting  its  border.     The 


660 


OPERATIONS 


faulty  cilia  are  firmly  seized  and  pulled  out  with  a  quick  motion,  .\fter  those  which 
are  readily  seen  have  been  removed,  search  should  be  made  (with  a  loupe)  for  others 
which  may  have  been  broken  off,  leaving  small  but  irritating  ends,  and  for  ver>-  fine 
white  hairs  which,  owing  to  their  lack  of  color,  may  escape  detection  with  the  un- 
aided eye. 

Removal  of  a  Meibomian  C>st. — This  may  be  removed  by  a 
conjunctival  incision.     A  sharp  scalpel  and  small  curet  are  required. 

The  lid  is  everted,  and  the  discolored  patch  marking  the  position  of  the  chala- 
zion is  made  prominent.     This  is  incised,  and  the  contents  are  scraped  out  with  the 


Fig.  278. — Chalazion  ciiret. 

curet.  The  cavity  thus  formed  fills  with  blood,  the  absorption  of  wliich  may  be 
hastened  by  the  use  of  hot  compresses.  This  operation  may  leave  a  slight  linear 
scar  in  the  conjunctiva  (Fig.  279).  It  is  an  advantage  to  continue  the  incision  to 
the  margin  of  the  lid  in  the  line  of  the  duct  as  recommended  by  John  Dunn. 

To  avoid  a  scar  the  lid  maj'  be  grasped  between  the  thumb  and  forefinger,  and 
by  pressure  a  drop  of  the  jelly-like  contents  made  to  appear  at  the  mouth  of  the 
Meibomian  duct.  A  few  drops  of  cocain  solution  are  injected  by  means  of  a  hypo- 
dermic syringe  the  needle  of  which  is  pushed  into  the  tumor  along  the  duct.  An 
incision  is  now  made  with  a  Graefe  knife,  following  the  course  of  the  needle.     A 

small  curet  is  introduced,  and  the  contents  of 
the  c\st  are  removed  (Agnew-Ray).  The 
subsequent  blood-clot  is  absorbed. 

External  chalazion  should  be  re- 
moved through  a  skin  incision,  the  lid 
being  steadied  in  a  clamp  (Fig.  280), 
and  the  cyst  dissected  from  its  bed  in 
the  ordinary  manner. 


Fig.    27'J. — Incision    of    a    clialazion 
(C'zerniak;. 


Fig.   280. — Knapp"s  lid  clanip. 


Operations  for  Ptosis. — Before  operating  for  the  relief  of  ptosis 
the  ain(juiit  of  powci-  residing  in  the  levator,  or  whether  it  has  any 
activity  at  all,  must  l)c  ascertained.  The  surgeon,  standing  in  fr(»nt 
of  the  patient,  firmly  depresses  the  eyel)ro\v  with  his  tlmmi)[and 
requires  the  subject  to  open  his  eyes.  Any  movement  of  the  lid  nuist 
l)e  due  to  the  levator,  as  the  pressure  on  the  brow  checks  the  frontalis 
action;  entiic  failure  of  lid  elevation  indicates  al>sence  <»f  levator 
power.  If,  tiie  frontalis  action  still  Ix'ing  elu'eked  and  the  IcNator 
pow(!r  absent,  there  is  slight  elevation  of  the  lid  when  the  eye  is  rolled 
upward,  it  is  due  to  the  action  of  the  superioi-  rectus,  from  which  a 
blind  passes  to  the  lev.-itor  tendon. 


OPERATIONS    FOR    PTOSIS  661 

All  operations  for  the  relief  of  ptosis,  and  many  have  been  devised, 
may  be  gathered  into  three  groups,  according  to  the  convenient  classi- 
fication of  Grimsdale  and  Brewerton:  (1)  Those  which  shorten  the  lid 
or  levator;  (2)  those  which  utihze  the  action  of  the  frontalis  muscle; 
(3)  those  which  utilize  the  action  of  the  superior  rectus. 

The  simplest  of  the  first  group,  namely,  an  elliptic  excision  of  a 
portion  of  the  skin  of  the  lid,  is  an  operation  which  should  not  be  per- 
formed on  account  of  its  inefficiency. 

Eversbusch's  Operation. — The  lid  is  drawn  downward  and  fastened  with 
Knapp's  clamp.  An  incision  is  now  made  through  the  entire  width  of  the  lid  mid- 
way between  its  margin  and  the  eyebrow,  which  divides  the  skin  and  orbicularis 
muscle.  The  edges  of  the  wound  are  separated  for  4  mm.  from  the  underlying 
tissue  above  and  below,  and  the  tendon,  which  is  thus  well  exposed,  is  next  included 
in  a  loop,  with  the  aid  of  three  double-armed  threads  passed  respectively  at  the 
center,  the  nasal,  and  the  temporal  margins.  Each  needle  is  now  thrust  vertically 
downward  between  the  tarsus  and  orbicularis,  brought  out  at  the  free  margin  of  the 
lid,  and  securely  tied  after  the  wound  on  the  surface  of  the  lid  has  been  closed  in  the 
usual  manner. 

This  operation  is  intended  for  the  relief  of  imperfect  action  of  the 
levator  and  is  designed  to  advance  its  insertion. 

Other  operations  belonging  to  this  class  are  advancement  of  the 
levator  tendon,  as  designed  by  Wolff  and  modified  and  improved  by 
Elschnig,  and  excision  of  a  semilunar  piece  of  tarsal  cartilage,  uniting 
the  edges  of  the  wound  with  sutures,  as  advised  by  Gillet  de  Grand- 
mont,  which  is  a  modification  of  an  operation  long  ago  suggested  by 
Bowman. 

To  the  second  group  belong  a  number  of  subcutaneous  thread  or 
wire  operations,  which  act  by  establishing  a  contracting  cicatrix  or  by 
supplying  an  artificial  tendon. 

Pagenstecher's  Subcutaneous  Thread  Operation. — A  silk  suture  armed  with 
two  needles  is  provided.  One  needle  is  introduced  close  to  the  ciliary  border  and 
passed  subcutaneously  for  2  mm.  parallel  to  the  ciliary  margin.  Next  the  same 
needle  is  re-entered  at  the  point  of  exit  and  passed  between  the  tarsus  and  skin  and 
brought  out  above  the  brow.  The  second  needle  is  introduced  at  the  point  of 
entrance  of  the  first  and  passed  upward  beneath  the  skin  to  the  point  of  exit  of  the 
first  above  the  brow.     Finally  the  sutures  are  tied. 

This  method  establishes  a  contracting  cicatrix  and  is  suited  to 
cases  of  incomplete  ptosis.  The  operation  was  modified  and  elaborated 
by  the  late  Mr.  Mules,  who  embedded  a  fine  loop  of  gold  wire  in  the 
tarsal  cartilage,  the  two  ends  from  which  passed  out  through  the  fron- 
tahs  and  which  remained  and  acted  as  an  artificial  tendon.  Worth  uses 
kangaroo  tendon  for  the  same  purpose,  and  Harman  "wove-chain" 
made  of  fine  wire,  which  is  passed  subcutaneously  from  the  lid  margin 
to  a  point  below  the  brow. 

A  number  of  operations  have  been  designed  to  form  a  union  between 
the  skin  of  the  lid  and  the  frontalis  muscle,  and  among  these  is  the 
well-known  Panas  operation,  which  consists  essentially  in  the  forma- 
tion of  a  small  cutaneous  flap  from  the  hd,  which  is  passed  through  an 


662 


OPERATIONS 


incision  under  the  brow  and  is  attached  to  tho  fibers  of  the  occipito- 
frontahs  muscle,  which  have  been  divided  b\'  an  incision  immediately 
above  the  brow,  and  which  has  cut  through  all  the  tissues  down  to  the 
periosteum.  This  operation,  once  much  employed,  is  now  rarely  per- 
formed probal)ly  because  it  is  apt  to  produce  an  unsifihtly  folding  of 
the  lid. 

J.  O.  Tansley  has  designed  a  combination  of  the  Pana-s  and  von 
Graefe  operation,  or  rather,  according  to  M.  L.  Foster,  a  modification 
and  improvement  of  Hunt's  operation,  with  which  the  author  has  had 
gratifying  success: 

"Two  perpendicular  and  parallel  cuts,  A-B,  C-D  (Figs.  281-283),  ^^inch  apart, 
are  made,  and  extend  from  the  upper  orbital  margin  to  within  two  lines  of  the  upper 
edge  of  the  lid.     These  cuts  are  united  at  the  upper  e.xtremity  by  a  horizontal  incis- 


FiGS.  281-283. — Tansley-Hunt  operation  for  congenital  ptosis. 


ion,  A-C,  and  the  ribbon  of  tissue  is  dissected  up  and  permitted  to  drop  down  upon 
a  wad  of  cotton  lying  on  the  cheek,  which  is  kept  moistened  with  a  warm  saline 
solution.  Next,  a  curved  cut  is  made  from  //  to  (1  and  from  E  to  F,  following  the 
crease,  which  shows  the  upper  limit  of  the  tarsal  cartilage,  and  a  straight  cut  is 
made  from  H  to  B  and  from  D  to  F,  parallel  to  and  about  two  lines  di.-^tant  from  the 
lower  border  of  the  lid.  The  skin  and  the  orbicularis  embraced  within  these  cuts 
are  now  carefully  dissected  off,  leaving  the  whole  tarsal  cartilage  denuded  of  tissue. 
The  cut  edges  //-6'  and  E-F  are  united  to  the  cut  edges  H-Buud  I)-F,  respectively, 
by  interrupted  sutures.  Next,  a  narrow  Graefe  knife  is  entered  at  A-<\  and  passed 
beneath  and  brought  out  upon  the  forehead  just  above  the  eyebrow,  and  slight 
lateral  cuttings  are  n)ade  so  as  to  give  room  for  the  pa.><sage  of  the  ribbon  of  skin 
which  has  been  dis.sected  up  at  the  first  stage  of  the  operation.  A  strong  suture 
placed  in  the  upper  edge  of  this  ribbon  of  skin  is  used  to  draw  it  up  into  the  cut 
made  beneath  the  eyebrow  and  bring  it  out  upon  the  forehead.  \\'hen  it  is  drawn 
up  sufhciently  tight,  it  is  cut  off  smooth  with  the  forehead  and  fastened  there  by 
two  small  sutures.  Then  several  sutures  are  plared  from  .1  to  G  and  ( '  to  E,  uniting 
the  edges  of  the  ribbon  to  the  bordering  derma.  "  The  operation  can  be  readily 
understood  by  reference  to  Figs.  2S1   2S;i. 

The  effect  of  this  opt'ration  is  well  shown  in  the  accompanying  illustration. 
.Although  the  tongue  of  skin  as  it  passes  beneath  the  brow  is  very  evident,  in  tl»e 
course  of  time  this  appearance  subsides  and  the  cosmetic  results  are  reasonably 
good. 


OPERATIONS  FOR  PTOSIS 


663 


Fig.  2S4. — Ptosis,  showing  stitches  in  Tansley-Hunt  operation  (from  a  patient  in^the 

University  Hospital). 


Fig.  285. 


Fig.  286. 
Ptosis — showing  results  of  Tansley-Hunt  operation. 


664 


OPERATIONS 


Hess'  Operation.— This  procedure  is  an  elal)oration  of  Pagcnstecher's  suture 
operation  and  acliiovps  excellent  results.      It  is  performed  as  follows: 

A  horizontal  incision  is  made  through  the  skin  of  the  shaved  eye-brow  as  long 
as  the  palpeljral  fissure  and  the  dissection  carried  on  imtil  the  skin  is  undermined 
almost  to  the  free  l)or(U'r  of  the  lid  in  its  entire  length,  forming,  therefore,  a  four- 
cornered  pocket.  Xe.xt  threestrongdoul)learmed  hlack  .silk sutures  are  introduced 
thus:  one  needle  of  the  first  or  middle  suture  is  pa.s.sed  through  the  skin  0  mm.  from 
the  lid  border  and  carried  in  beneath  the  skin  and  between  it  and  the  orbicularis 
muscle  to  the  line  of  the  first  incision;  the  second  needle  of  the  suture  is  similarly 
passed,  having  been  introduced  about  5  mm.  from  the  jwint  of  entrance  of  the 
first  needle.  In  like  manner  at  a  distance  of  1  cm.  on  each  side  of  the  middle 
suture  the  two  remaining  double  armed  threads  are  passed.  Following  this  the 
needles  of  the  middle  suture  are  made  to  penetrate  deeply  from  the  upper  edge 
of  the  original  skin  incision  clo.se  to  the  periosteum  and  hence  beneath  the  muscle 


Fig.  287. — Result  of  a  Hess  upfrutiou  for  ptosis,  shuwint;  on  loft  sido  the  position  of  the 
stitches  (from  a  patient  operated  upon  by  Dr.  T.  B.  Holloway). 

and  brought  out  a  few  niiilinictcrs  above  tlic  l)row  or  about  l.o  to  2  cm.  from  the 
first  incision.  The  same  maneuver  is  repeated  with  the  lateral  sutures,  the 
inner  one  being  inclined  slightly  toward  the  median  line.  The  sutures  are  tied, 
the  thread  being  drawn  tightly,  over  small  rolls  of  surgical  gauze  or  short  jjieces  of 
narrow  drainage  tube.  Thus  the  lid  is  raised,  and  the  skin,  folded  on  it.self,  is  in 
the  position  of  the  natural  fold  and  establishes  a  new  ailhesion  to  the  muscle. 
A  few  interrupted  sutures  close  the  lips  of  the  original  incision.  These  sutures 
may  \)C  removed  at  the  end  of  three  days,  but  the  other  sutures  should  rem:iin  for 
at  least  two  weeks.  To  protect  the  ojjcn  eye  it  may  be  covered  with  a  celhiioid 
shield  shaped  like  a  large  watch  crystal  fastened  with  strips  of  gauze  and  collodion 
or  a  King's  mask  (Fig.  'Ml)  into  wliich  a  stpiare  window  is  cut,  to  be  covered  with 
a  layer  of  gauze,  may  be  fitted  over  the  fac(>.  The  suture  lines  m.-iy  be  painted 
with  Whitehead's  varnish  or  with  a  ii  per  cent,  solution  of  lodin. 

( )tlici-  operations  iicloiij^iii^  lo  t  liis  ^roiip  ;iit'  W  .  II.  \\  iMn's  proced- 
ure, who  folds  upon  itseli'  the  I  arso-orl)il;d  fascia  and  est;il»iishes  a  lirrn 
jidhesioii  hclwccM  the  lu-sciji  and  (lie   front jdis  niuscle.  1mm>>;iis'  iiiethoil 


TARSORRHAPHY 


665 


of  attaching  a  strip  of  the  frontalis  to  the  lid,  and  Sourdille's  modus 
operandi,  bj'  which  the  levator  tendon  is  fastened  to  the  frontahs. 

Finally  are  those  operations  which  depend  for  their  effect  upon  a 
utihzation  of  the  action  of  the  superior  rectus.  Among  them  the  one 
most  frequenth^  employed  is  that  designed  by  ^Nlotais  (Motais'  opera- 
tion), which  consists  essentially  in  attaching  a  narrow  tongue  of  tissue 
formed  from  the  center  of  the  tendon  of  the  superior  rectus,  through  an 
opening  in  the  conjunctival  surface  of  the  everted  Hd,  to  the  upper  bor- 
der of  the  tarsus,  where  it  is  fastened  by  means  of  sutures  which  are 
brought  out  through  the  tarsus  and  hd  skin  and  tied  on  the  outer  side 
of  the  hd.  While  this  operation  has  certain  attractive  features,  it  may 
be  followed  by  temporary  diplopia  and  depression  of  the  eyeball.  If 
the  sutures  are  tied  over  the  conjunctiva,  the  knot  may  cause  local 
irritation.  It  is  warmly  commended  by  H.  D.  Bruns.  If  the  tendon 
of  the  superior  rectus  is  poorly  developed,  W.  T.  Shoemaker  suggests 
that  the  entire  tendon  of  the  rectus  muscle,  in  place  of  a  single  central 
strip,  shall  be  fastened  to  the  tarsus  in  the  manner  described. 

After  any  of  these  operations,  performed  with  the  usual  aseptic  pre- 
cautions, the  ordinary  dressings  should  be  apphed  and  the  sutures  re- 
moved at  the  end  of  a  week.     The  anesthesia  may  be  local  or  general. 

Tarsorrhaphy. — This  operation  is  designed  to  shorten  an  abnor- 
mally wide  palpebral  fissure  {lateral  or  angular  tarsorrhaphy)  or  to  close 


Fig.  288. — Lateral  tarsorrhaphy. 


temporarily  the  Kds  over  the  eyeball  (median  tarsorrhaphy). 
tarsorrhaphy  is  performed  as  follows: 


Lateral 


The  external  commissure  is  taken  between  the  thumb  and  index-finger,  the 
fissure  of  the  lids  closed  to  the  required  extent,  and  the  line  of  incision  marked  with 
an  anilin  pencil.  A  horn  spatula  or  shield  is  now  introduced  between  the  lids,  and 
a  flap  removed  from  the  free  margin  of  each  hd  near  the  external  commissure;  this 
must  contain  all  the  hair-foUicles.  The  breadth  of  the  flap  is  1  mm.  and  the  length 
about  4  mm.  To  obtain  still  firmer  union  the  ciliars'  margin  may  be  denuded  for 
several  millimeters  beyond  the  point  of  removal  of  the  flap,  but  in  this  incision  the 
cilia  must  not  be  injured.  The  edges  are  approximated  by  silk  sutures.  Figure 
288  explains  the  steps:  a  indicates  the  point  of  union  of  the  two  flap  wounds  behind 
the  commissure:  b.  b,  the  termination  of  the  flap  wounds  in  the  lid-margins;  and  c, 
c,  the  end  of  the  denudation  of  the  cihary  margins. 


666  OPERATIONS 

Median  targorrhapliy  is  accomplished  by  denuding  the  cihan-  margin  of  the 
center  of  each  lid  for  4  mm.,  the  lashes  being  untouched,  and  approximating  the 
denuded  edge  with  a  mattress  suture.  The  ej-eball  is  thus  effectually  covered,  but 
the  cornea  can  be  inspected  if  the  globe  is  rotated  either  inward  or  outward  through 
the  narrowed  lid  interspace  on  each  side  of  the  central  attachment. 

Angular  tarsorrhaphy  is  indicated  in  ectropion  in  order  to  raise  the 
angle  of  the  lid,  and  in  lagophthalnios  and  exophtiialnios  to  improve  the 
unsightly  appearance  and  to  protect  the  cornea. 

Median  tarsorrhaphy  is  suited  to  those  conditions  in  which  the 
cornea  must  be  protected,  for  example,  in  exposure-keratitis,  facial 
palsy,  and  to  prevent  ulceration  after  removal  of  the  Gasserian  gang- 
lion (page  284). 

Canthoplasty  (Blepharototny). — This  operation  is  performed  to 
enlarge  an  abnornialh"  short  palpebral  fissure. 


Fig.  289. — Canthoplasty.     The  stitches  ready  to  be  tied  (Haab). 

One  blade  of  a  pair  of  probe-pointed  scissors  is  introduced  behind  the  external 

commissure,  and  the  entire  thickness  of  the  tissues  is  divided,  making  the  wound  in 
the  skin  a  little  longer  than  that  in  the  conjunctiva.  The  wound  margins  are  next 
separated,  and  the  surgeon  loo.sens  the  conjunctiva  at  the  apex  of  the  incision  and 
frees  it  from  the  underlying  tis.sue.  Three  sutures  are  passed,  one  uniting  the  ex- 
tremity of  the  conjunctival  flap  to  the  center  of  the  skin  incision,  and  one  suture 
above  and  one  below,  near  the  angles  of  the  wound.  Division  of  the  external  can- 
thus  without  subsequent  introduction  of  sutures  is  known  as  canthutomy. 

Canthoplasty  is  frequently  performed  for  the  relief  of  the  con- 
tracted fissure  which  follows  long-standing  trachoma  and  certain 
types  of  chronic  blepharitis,  and  also  to  lessen  the  tension  (Hi  flaps  in 
various  tj'pes  of  l)I('ph:ii()plasly.  Axenfcld  recoiiiniends  bkphorotomy 
prior  to  cataract  extraction  where  the  palpel»ial  (issuic  is  I'xtreiuely 
narrow. 

Operations  for  Trichiasis.  If  only  a  few  hairs  are  involved,  the 
olTendirig  hishes  should  be  extracted  with  ciHiuu  forceps  in  the  iii;imiei- 
already  described. 


DOUBLE-TRANSPLANTATION  OPERATIONS  667 

Electrolysis,  as  originally  suggested  by  Michel,  of  St.  Louis,  may 
be  performed  as  follows : 

A  platinum  or  iridium  needle  attached  to  the  negative  pole  of  a  constant  battery 
is  inserted  into  the  follicle  of  the  lash  which  is  to  be  removed.  A  sponge  electrode 
attached  to  the  positive  pole  is  applied  to  the  cheek  and  the  current  closed.  A  drop 
of  froth  appears  around  the  needle,  which  should  be  kept  in  place  for  a  few  seconds 
and  then  withdrawn.     The  lash  is  easily  removed. 

For  complete  distichiasis  some  form  of  transplantation  should  be 
employed.  The  Jaesche-Arlt  operation,  once  often  employed,  is  not 
satisfactory,  and  has  been  abandoned  for  more  rational  procedures. 


Fig.  290. — Method  of  making  the  intermarginal  incision  (Czermak). 

DoubIe=transpIantation  operations,  or,  in  other  words,  the 
manufacture  of  an  artificial  lid-border  by  transplanting  a  strip  of  skin 
to  the  intermarginal  space,  have  been  practised,  especially  since  Spen- 
cer Watson's  suggestion. 

F.  C.  Hotz  designed  the  following  valuable  method  which  the 
author  employs  with  most  satisfactory  results: 

The  lid-border  is  split  by  the  well-known  intermarginal  incision  (Fig.  290),  after 
which  a  transverse  incision  is  made  through  the  lid-skin  and  the  orbicularis  muscle 
just  below  and  parallel  with  the  upper  line  of  the  tarsal  cartilage.  The  strip  of 
muscular  fibers  which  covers  the  upper  portion  of  the  cartilage  is  excised,  and  the 
lid-skin  is  united  with  the  upper  border  of  the  cartilage  by  three  sutures.  Each 
suture  passes  through  the  edge  of  the  lid-skin,  then  through  the  upper  border  of  the 
cartilage,  and  finally  through  the  upper  edge  of  the  cutaneous  wound  (Figs.  291, 
292).  After  the  sutures  are  tied,  the  skin  of  the  lid  is  drawn  upward  and  fastened 
to  the  upper  border  of  the  tarsus.  By  this  means  a  thorough  eversion  of  the  an- 
terior edge  of  the  split-lid-border  is  effected,  and  the  intermarginal  incision  is 
conA'erted  into  a  gaping  wound  several  millimeters  in  depth.     This  groove  is  filled 


668 


OPERATIONS 


with  a  skin-graft,  lonp  and  narrow  and  .somewhat  wcdK^-shaped,  which  preferably 
is  removed  from  the  intejiument  behind  the  ear.  It  should  be  from  1  '2  to  2  mm. 
in  width,  and  of  a  proper  length  to  fill  the  ojjening.  The  graft  i.s  spread  (»ut,  gently 
pres.sed  into  the  groove  (Fig.  293),  and  after  thorough  irrigation  with  a  saline 
solution  both  eyes  are  covered  with  a  compress  bandage.  During  the  first  two 
weeks  the  epidermis  of  the  graft  is  repeatedly  shed,  and  it  is  advisable  to  keep  the 
new  lid-border  well  lubricated  with  l)ichlorid-vaselin  (1:3000). 


Figs.  291 


Operation  of  AnuKuostakis  and  Hotz. 


Because  the  fine  cutaneous  hairs  in  the  transplanted  flap  sometimes 
irritate  the  cornea  Van  MilHngen  proposed  his  tarsocheiloplastic  opera- 
tion, in  which  the  intermarginal  gap  is  covered  ^vitll  a  strip  of  mucous 
membrane  taken  from  the  inner  surface  of  the  imder  hp. 

Operations  for  Entropion.— Several  methods  of  correcting  spas- 
modic entropion  have  been  referred  to  on  page  193.     Gaillard's  suture 


Fio.  293. — Reconstrufrtion  of  the 
lid-l<ordor  (Hotz). 


Fitj.   204. — C'ro8S-har  entropion  forceps. 


is  also  useful;  tlu^  skin  of  the  lid  is  temporarily  shortened  by  means  of  a 
fold  caught  in  one  or  two  sutures.  In  the  spasmodic  tnlropiott  of 
elderl}'  people  the  following  opciatioii  may  be  performed: 

With  entropion  forceps  a  strip  of  skin  of  suitable  witltli,  i)ar.dlel  to  the  ciliary 
border  of  the  lid,  is  pinched  up.  This  strip,  together  with  the  subj.ncent 
fibers  of  the  orbicularis  muscle,  is  excised.  The  wound  is  cK)scd  with  silk  sutures 
and  dressed  in  tlic  r)rdiimrv  wav.      The  sutures  are  removed  on  the  third  d.-iy. 


OPERATIONS     FOR    ENTROPION  669 

Instead  of  excising  a  horizontal  fold  of  skin,  excision  of  a  triangular  portion  may 
be  performed  (von  Graefe).  The  base  of  the  triangle  is  placed  3  mm.  from  the 
ciliarj'  margin,  and  the  width  and  length  are  calculated  according  to  the  looseness  of 
the  tissues.  After  the  flap  is  excised  the  margins  are  freed  and  brought  together 
with  sutures,  but  no  sutures  are  applied  to  the  horizontal  incision.  If  necessary, 
the  subjacent  tarsal  cartilage  may  be  removed. 

In  organic  entropion  an  operation  must  be  performed  which  will 
not  mereh'  evert  the  misplaced  border,  but  also  alter  the  curve  of  the 
tarsal  cartilage,  which  usually  has  become  thickened.  Two  operations 
will  be  described: 

Burow's  Operation. — This  operation  is  designed  to  reheve  entropion 
of  the  upper  hd  following  trachoma.     It  is  performed  as  follows: 

The  upper  lid  is  thoroughly  everted,  and  the  gray-white  scar-line  (see  page  234), 
which  runs  parallel  with  the  margin  of  the  lid  is  exposed.  At  the  temporal  end  of 
this  line  an  incision  is  made  sufficiently  large  to  admit  a  fine  grooved  director,  which 
is  now  pushed  to  the  nasal  side  of  the  lid  between  the  skin  and  the  conjunctiva,  care 
being  taken  that  the  point  of  the  director  is  kept  well  beneath  the  cicatricial  tissue. 
The  tissue  thus  elevated  is  divided  in  its  whole  length,  either  with  a  sharp  scalpel 
or  with  narrow  scissors.  ^Mien  the  operation  is  completed  a  blue  line  equal  in 
length  to  the  line  of  incision  should  appear  upon  the  cutaneous  surface  of  the  hd. 
No  dressing  is  required,  or.  at  most,  cold  compresses  to  allay  the  irritation.  The 
cicatricial  contraction  which  ensues  everts  the  incur\'ed  border  of  the  hd. 

Although  the  operation  is  usually  primarily  successful,  its  effects 
generally  do  not  long  remain,  and  recurrence  of  the  entropion  takes 
place.     The  operation  may  be  repeated  several  times. 

Hotz-Anagnostakis  Operation. — This  procedure,  as  it  was  prac- 
tised by  Dr.  Hotz,  is  described  in  his  own  words,  as  follows: 

"A  transverse  incision  from  canthus  to  canthus  is  made  through  skin  and  sub- 
jacent tissues,  but  instead  of  being  made  near  and  parallel  with  the  free  border  (as 
in  the  former  methods)  the  incision  in  this  operation  is  to  follow  the  tipper  border 
of  the  tarsus.  It,  therefore,  describes  a  sUght  curve  beginning  and  ending  at  a 
point  about  2  mm.  above  the  canthus,  but  being  6  to  8  mm.  distant  from  the  free 
border  in  the  center  of  the  hd.  WTiUe  an  assistant  is  holding  the  edges  of  the  wound 
well  separated,  the  surgeon  lifts  up  with  forceps  and  excises  with  scissors  a  narrow- 
bundle  of  the  muscular  fibers  which  run  transversely  along  the  upper  border  of  the 
tarsus.  Next  the  sutures,  which  are  to  include  nothing  but  the  cutaneous  wound 
borders  and  the  upper  border  of  the  tarsus,  are  inserted.  The  first  suture  is  placed 
in  the  center  of  the  hd;  the  curved  needle,  armed  with  fine  black  aseptic  silk,  is 
passed  through  the  lower  wound  border;  there  taken  again  in  the  needle-holder,  it 
is  boldly  thrust  through  the  upper  border  of  the  tarsus,  and  returned  through  the 
tarso-orbital  fascia  just  above  this  border;  and  finally  it  is  carried  through  the 
upper  wound  border  (Fig.  291,  o,  h).  One  similar  suture  is  placed  at  each  side 
of  the  central  one,  and  these  three  stitches  are  usually  sufficient  for  our  purpose — 
to  wit,  to  draw  the  skin  of  the  eyehd  up  toward  the  upper  border  of  the  tarsus  and 
estabhsh  a  firm  union  between  these  parts.  This  artificial  union  produces  a  shght 
tension  of  the  tarsal  skin,  which  however,  is  sufficient  to  relieve  any  ordinary  degree 
of  entropion. 

''But  when  the  lids  have  been  badly  contracted — when  the  palpebral  aperture 
has  become  unnaturally  narrow,  or  the  free  border  of  the  hd  has  become  entirely 
merged  into  the  plane  of  the  conjunctiva — these  complicated  cases  require,  in 
addition  to  the  above  operation,  such  surgical  measures  as  canthotomy,  the 
restoration  of  the  free  border  either  by  grooving  the  tarsus  or  by  grafting"  (see 
description,  page  667,  Fig.  293). 


670 


OPERATIONS 


Tliis  is  a  most  satisfactory  operation,  and  the  results  in  the  author's 
experience  have  been  excellent.  If  grooving  the  cartilage — that  is. 
cutting  a  groove  or  narrow  gutter  along  the  center  of  the  tarsus  from 
one  end  to  the  other — is  combined  with  the  Hotz-Anagnostakis  opera- 
tion, the  double  knife  and  clamp  devised  by  W.  H.  Wilder  may  be 
employed  (F'ig.  295).  This  knife  is  also  most  useful  for  cutting  the 
narrow  graft  of  skin  which  may  be  required  to 
restore  the  lid-border  and  which  is  applied  in  the 
manner  already  described  (see  page  668). 

Although  the  operations  for  trichiasis  and 
entropion  have  been  separated  in  the  descriptions, 
it  must  be  remembered  that  these  two  conditions 
are  constantly  associated,  and  hence  their  surgical 
treatment  in  most  particulars  is  identical.  Many 
other  operations  for  the  relief  of  these  and  other 
lid  affections  have  been  devised,  but  necessarily  the 
author  has  described  only  few  standard  methods, 
and  especially  those  which  have  given  him  personal 
satisfaction. 

Operations  for  Ectropion. — If  ectropion  is 
associated  with  relaxation  of  the  tissues,  an  eversion 
of  the  conjunctiva,  as  is  often  seen  in  old  people 
{senile  ectropion),  excision  of  a  V-shaped  piece  of 
the  whole  thickness  of  the  hd  may  be  practised. 
This  procedure  may  be  understood  by  a  reference 
to  Fig.  296.  Instead  of  making  the  triangular 
excision,  as  it  is  in  the  illustration,  it  may  be  placed 
at  the  external  canthus,  and  thus  disfiguring  scars 
are  avoided. 

In  place  of  Adams^  operation  for  short (Miing  the 
lid-l)order,  Miiller's  modification  of  Kuhnt's  oper- 
ation may  be  practised  and  can  be  recominend(>d 
(Kuhnt-MuUcr  operation) . 

Kuhnt-Miiller  Operation. — \\'ith  a  broad,  triangular 
knife  a  deep  incision  is  made  into  the  center  of  the  lid- 
niargin,  which  divides  the  lid-substance  into  two  portions, 
the  one  containing  the  conjunctiva  and  the  tarsus,  and  the 
other  the  soft  tissues  and  the  skin.  From  the  fii-st  portion 
a  triangular  piece  is  removed  by  the  aid  of  two  incisions 
which  should  converge  toward  tiie  fornix  (Fig.  207,  A,  a-c  and  l^c).  The  two 
portions  of  the  lid  are  next  separated  toward  the  external  canthus  by  carrying 
the  knife  from  under  the  margin  b-c  toward  d.  Next,  the  V-shaped  wound  of 
the  tarsus  is  closed  with  sutures,  and  the  long  stretch  of  the  skin  margin, 
fl-a,  is  \mited  with  the  shorter  margin,  d-b,  of  the  tarsus  by  means  of  sutures. 
Their  method  of  application  may  be  understood  by  examining  Fig.  LMlT,  H.  The 
jjuckering  which  occurs  after  these  sutures  are  tied  disapj)ears  and  the  lid-margin 
becomes  smootli. 

Kuhnt-Szymanowski     Operation.  -An     even     more    satisfactory 
operation  for  llic  relief  of  senile  ectropion  is  a  (•oml)iiiation  of  the 

met  hods  oi"  Kiiliiit  ami  S/\-in;inowski. 


Fig.  295.  — Wilder'a 
double  knife. 


OPERATIONS    FOR    ECTROPION 


671 


The  first  step  of  the  operation  (Fig.  298)  is  performed  exactly  as  in  the  Kuhnt- 
Mtiller  procedure  (see  Fig.  297).  The  next  step  consists  in  the  excision  of  a  tri- 
angular piece  of  the  skin  at  the  external  canthus  in  the  manner  indicated  in  the 
diagram  (Fig.  299).  The  base  of  this  triangle  should  be  somewhat  longer  than  the 
base  of  the  triangular  piece  which  has  been  excised  from  the  tarsus.  A  second 
incision  is  carried  from  the  canthus  downward  and  slightly  outward,  and  should  be 
twice  as  long  as  the  incision  from  a  to  h.  Finally,  the  two  incisions  are  united  in 
such  a  manner  that  the  triangular  piece  of  skin  can  be  excised.  The  skin  of  the 
lid  is  next  thoroughly  undermined,  so  that  it  may  be  easily  drawn  outward  to 


Fig.  296. — Adams'  operation  for  ectropion  by  excision  of  a  V-shaped  piece  of  the  lid. 

cover  the  defect  which  has  been  produced  by  the  excision  of  the  triangular  area  at 
the  outer  canthus.  The  operation  concludes  with  the  insertion  of  silk  sutures  in 
the  manner  shown  in  Fig.  300. 

Snellen's  Suture  Operation. — A  suture  armed  with  a  needle  at  each  end  is 
provided.     One  needle  is  entered  at  the  junction  of  the  external  and  middle  third 

A  B 


Fig.  297. — A,  Shortening  of  lid-border  after  manner  of  Kuhnt  and  Miiller;  B,  Kuhnt- 
Miiller  operation,  final  stage  (Hotz). 

close  to  the  posterior  border  of  the  tarsus,  and  is  passed  down  beneath  the  skin  of 
the  lid  to  a  point  at  the  summit  of  the  lower  margin  of  the  orbit,  and  is  there 
brought  out.  The  second  needle  is  entered  at  a  point  5  mm.  from  the  first,  and 
with  the  other  end  of  the  thread  is  carried  down  close  to  the  first  and  parallel 
with  it.  The  two  extremities  of  the  suture  are  tied  upon  the  cheek  over  a 
piece  of  drainage-tube.  The  same  procedure  is  repeated  with  a  second  double- 
armed  suture,  the  points  of  entrance  being  at  the  junction  of  the  middle  and  inner 
third  of  the  conjunctival  surface.  This  operation  is  suited  to  cases  of  spastic 
ectropion.  It  has  been  employed  in  senile  ectropion,  but  has  in  these  circumstances 
no  valuable  permanent  effect. 


672 


OPERATIONS 


Galvanocaulery  puncture  is  recommended  by  S.  Lewis  Ziegler  for 
the  relief  of  ectropion  and  entropion.  A  lid-damp  is  adjusted  and  the 
galvanocautery  point  is  pushed  through  the  cartilage  and  cjuickly 
withdrawn.  The  punctures  are  made  4  mm.  from  the  lid  margin, 
and  separated  from  each  other  b}'  an  interval  of  4  mm.  They  are 
made  on  the  conjunctival  surface  in  ectropion,  and  skin  surface  in 
entropion. 


Fig.  298. 


-Showing  the  division  of  the  Hd  into  two  portions  and  the  ex(^ision  of  the 
triangle  of  thickened  conjunctiva  and  tarsus. 


I 

I 


The  operations  for  the  relief  of  ectropion  thus  fai  described 
are  in  general  terms  suited  only  to  those  types  of  this  lid  de- 
formity unassociated  with  loss  of  tissue  after  injury  or  removal  cf 
growths,  scar-tissue  and  the  results  of  contracting  cicatrices.  In  the 
presence  of  such  complications  operations  of  much  more  formal  char- 
acter and  elaborate  technic  are  required,  which  for  the  main  part  are 
classified  as: 


I'll..  l."J'.t.      Sliowing  tlic  forniiilion  of  tin- 
triangle  of  skin  which  is  later  removed. 


--*- 

.  vt  ^ 

\    /S 

? 

k^^^ 

^ 

^ 

W'\     'ffiv' 

^ 

0 

^^^B 

Wt^^KT^Ii 

^ag^ 

% 

F 

— — 'Tm^  .^3 

\^/i 

f 

L 

\ 

1 

Ik..  .{(Ht.  Showing  the  conililuni  alter 
the  excision  of  the  t riaiigiilitr  piece  t»f  skin 
and  the  iitiderinining  of  the  lid,  which  is 
ttirneil  outward.      The  sutures  are  in  place. 


Wharton  Jones'  Operation.  .\  liorn  spaliiia  i.s  j)iit  into  po.sitioii  to  protect  the 
eye,  iind  a  V-sliaped  incision  is  inadc.  Tlie  (lap  is  then  .separated  siiljieiently  to 
eriahle  the  lid  (o  lie  |)iislied  up  into  |)laee.  The  lower  part  of  the  woiiinl  is  drjiwn 
togetlier  with  sutures,  thus  converting  the  V  into  a  Y.  The  tri.'ingular  Haps  shoidd 
uiclude  tlie  cicatrix  which  lias  |)ioduced  the  cuiginal  troulde.      (  KijC-  301.) 


OPERATIONS   FOR   ECTROPION 


673 


Neither  Adams'  nor  the  V  Y  operation,  although  occasionally 
useful,  as  a  rule  meets  the  indications  for  correction  presented  by 
cicatricial  ectropic  conditions,  hence  the  chief  reliance  must  be  placed 
on  the  other  methods  briefly  summarized. 

Other  Operations  for  Ectropion. — In  cases  where  the  lid  de- 
formity is  not  too  elaborate  the  following  procedure  may  be  put  into 
operation : 

1.  Epidermic  Grafts  for  the  Correction  of  Ectropion.  ^ — The  ectro- 
pionized  lower  lid.  for  example,  is  dissected  free  of  attachments  in 
such  a  manner  that  it  can  be  drawn  upward  well  over  the  upper  lid 
and  held  in  place  by  three  sutures  inserted  in  its  margin  and  passed 
through  a  strip  of  firm  zinc  plaster  fastened  horizontally  above^the 
brow.  All  underlying  cicatricial  bands  are  divided  and  scarred  tissue 
removed.  The  denuded  area  which  presents  itself  is  covered  with  a 
large  Thiersch  graft,  which  should  be  cut  thin  from  the  inner  aspect 
of  the  arm,  and  which  should  be  larger  than  the  surface  it  covers,  and 
pressed  neatly  and  smoothly  into  position.      No  dressing  of  any  kind 


Fig.  .301. — Wharton  Jones'  operation  for  ectropion. 


need  be  placed  on  the  graft,  but  it  may  be  exposed  to  the  air,  and  even 
better,  when  possible,  to  the  sunlight;  At  first  there  is  considerable 
wrinkling  of  the  Thiersch  graft,  gradually  this  disappears  and  ulti- 
mately, in  successful  cases,  the  surface  is  smooth.  The  stitches  are 
removed  at  the  end  of  ten  days  or  two  weeks. 

The  tissue  of  the  cheek  below  the  area  denuded  bj^  the  dissection 
of  the  ectropionized  lid  should  be  supported,  to  prevent  its  sagging, 
by  suitable  strips  of  plaster."  Naturally,  the  same  procedure  applies 
to  an  ectropion  of  the  upper  lid,  which  after  being  freed  is  drawn 
downward  over  the  lower  lid,  and  is  fastened  as  before  to  the  sub- 
jacent tissue  of  the  cheek. 

2.  Epithelial  Overlay. — Should  there  be  decided  loss  of  tissue,  as 
the  result  of  a  burn,  for  example,  and  an  extensive  dissection  and 
undermining  be  required  in  the  removal  of  scar  tissue  before  the  eyelid 
can  be  sutured  into  a  favorable  position  an  epithelial  overlay,  as  Gillies 
suggests,  can  be  utilized  as  follows: 

43 


674  OPERATIONS 

An  impression  of  the  entire  raw  surface  is  taken  with  dental  modeling  composi- 
tion; next  the  denuded  are  a  is  covered  with  a  Thiersch  graft  and  kept  firmly  in 
place  with  the  previously  prepared  mold  or  impression.  This  operation,  as  Han- 
ford  McKee  points  out,  may  obviate  the  necessity  of  forming  a  pedunculated  flap. 
It  is,  in  fact,  an  elaboration  of  the  procedure  just  described. 

3.  Free  Dermic  (Whole-skin)  Grafts  for  Correction  of  Ectropion. — 

In  place  of  a  Thiersch  (epidermic)  graft,  as  previously  described,  a  free 
Wolfe  (dermic,  "whole-skin")  graft  may  be  employed,  which  in  the 
opinion  of  some  surgeons,  notably  John  ]\L  Wheeler,  far  exceeds  in 
effectiveness  either  an  epidermic  layer  or  a  pedunculated  flap. 

The  bed  which  is  to  receive  the  graft  is  prepared  practically  in  the  manner  al- 
ready described,  by  making  a  skin  incision,  a  few  millimeters  from  the  Ud  margin 
(usually  it  is  the  lower  lid),  of  the  same  length  as  the  palpebral  fissure  and 
thoroughly  dissecting  out  all  cicatricial  tissue,  but  sacrificing  the  muscular  tissue  as 
little  as  is  possible.  Next  the  Hds  are  fastened  together  at  three  equidistant  points 
(interrupted  tarsorrhaphy  [see  page  665]) ,  and  the  denuded  area,  all  bleeding  having 
been  checked  without  use  of  sutures,  is  put  on  stretch  by  means  of  strips  of 
plaster  above  and  below,  and  a  dermic  graft  prepared  as  directed  on  page  679 
is  transferred  into  position  and  carefuUj'  sewed  in  place.  The  grafted  area  is 
greased  with  White's  ointment  or  .sterilized  vaseline  ("Wheeler)  over  which  a  piece 
of  thin  rubber  tissue  is  spread ;  on  top  of  this  is  placed  surgical  cotton  and  the 
whole  secured  by  means  of  a  pressure  bandage.  The  dressings  should  not  be  re- 
moved for  at  least  five  daj^s. 

The  author  agrees  with  Wheeler  and  other  advocates  of  this  pro- 
cedure that  it  represents  a  most  valuable  method  of  deahng  with 
cicatricial  ectropion,  but  he  is  also  convinced  that  epidermic  grafts, 
as  advocated,  have  an  important  relation  to  the  treatment  of  cicatricial 
ectropion.  The  method  of  sewing  the  lids  together  is  indicated  if  the 
ej'eball  is  in  place ;  if  not  they  must  be  anchored  to  the  orbital  contents. 

Plastic  Operations  on  the  Eyelids  (Blepharoplasty^). — 
Much  can  be  accompUshed  in  the  early  treatment  of  wounded  and 
lacerated  eyelids  and  their  surroundings,  and  thus  prevent  the  sub- 

*  Plastic  operations  on  the  eyelids  have  necessarily  greatly  increased  in  number 
as  the  result  of  war  injuries.  In  many  instances  the  operation  is  not  alone  con- 
cerned with  the  eyelids,  but  owing  to  extensive  or  multiple  wounds  is  concerned 
with  the  larger  problems  of  maxillofacial  surgery,  and  therefore  the  plastic  surgeon 
and  the  ophthalmologist  may  often  find  it  of  advantage  to  work  together.  The 
site  and  character  of  the  lesion  will  in  each  instance  determine  the  best  method  of 
procedure,  and  it  would  not  be  possible  in  a  chapter  of  the  present  scope  to  indicate 
in  detail  the  numerous  ingenious  methods  which  have  been  devised  for  the  correc- 
tion of  cicatricial  ectropion  by  these  blepharoplastic  operations,  or  for  the  forma- 
tion of  an  entirely  new  lid  to  replace  one  that  has  been  destroyed  by  some  disease, 
such  as  lupus,  or  by  injury.  For  tho.se  interested  a  large  literature,  foreign  and 
American,  is  available.  Particular  attention  is  directed  to  Plastic  Surgery  of  tlie 
Face,  by  H.  D.  (lillics,  Oxford  I'niversity  Press,  I'fJO;  Plastic  Operations  on  the 
Orbital  Kegion,  including  I{estoration  of  the  Eyebrows,  Kyeiids  and  Orbital 
Cavity;  Powman  Lecture  by  \.  Morax,  Tran.sactions  of  the  Ophtluilmological 
Society  of  the  I'nited  Kingdom,  \'ol.  xxxix,  1919;  ^^'ar  Injuries  of  the 
Eyelids,  by  John  M.  \\  heeler,  Tran.-^actions  of  the  American  Ophthalmnlog- 
ical  Society,  Vol.  xvii,  1919,  niul  Dermic  (irafts  for  Correction  of  Cicatricial 
]'>,troj)ion,  Amer.  Jour,  of  Ophtli.iluiology,  .\j)ril,  1920;  Heparative  Surgery 
after  War  Injuries  of  the  Eyes,  by  (!.  11.  (Irout,  Archives  of  Ophtlialmology 
Vol.  xlviii.  No.  :i,  1919. 


I 


PEDUNCULATED    FLAPS  675 

sequent  deformities  and  contractions.  Scrupulous  aseptic  cleansing  of 
the  injured  areas  is  of  paramount  importance,  and  as  Gillies  well 
maintains,  all  tissue  should  be  retained  the  retention  of  which  is  feasible ; 
it  should  be  put  back  into  its  normal  place  at  as  early  a  date  as  possible. 
Stitches  must  be  neatly  inserted  and  with  due  regard  to  a  coaptation 
of  the  lacerated  parts  in  their  proper  positions. 

Before  attempting  the  correction  of  lid  deformities  it  is  important 
to  eliminate  sources  of  infection  in  their  neighborhood;  suppuration  of 
the  conjunctival  mucous  membrane  by  suitable  antiseptic  irrigation; 
pus  in  the  lacrimal  sac  by  its  excision;  and  purulent  secretion  of  the 
ethmoid,  frontal,  and  antral  sinuses. 

In  general  terms,  lid  deformities  may  be  corrected  by  whole-skin 
or  epidermic  grafting  (Wolfe-Lefort  flaps  or  Thiersch  grafts),  by  the 
use  of  pedunculated  flaps,  b}'  excision  of  a  V-shaped  piece  of  the  lid 
(Adams'  operation  Fig.  671),  or  the  V  Y  operation  (Wharton  Jones' 
operation),  by  the  Esser  epithelial  inlay,  and  the  Gillies'  epithelial 
outlay  or  overlay. 

Epithelial  Outlay  for  the  Correction  of  Ectropion  (Gillies'  Opera- 
tion).— -Using  Esser's  inlay  operation  (page  680)  as  a  basis.  Gillies  has 
developed  a  method  bj^  which  the  skin  surface  of  an  eyelid  is  so  aug- 
mented as  to  correct  the  ectropion.  His  procedure,  quoting  his  own 
description,  slightly  condensed,  is  as  follows: 

"For  ectropion  of  the  upper  lid  a  curved  incision  is  made  just  above  the  lid 
margin.  This  is  deepened  slightly,  but  not  down  to  the  tarsal  plate,  and  care  is 
taken  to  avoid  interference  with  the  levator  palpebrse  superioris  muscle.  To  a 
certain  extent  the  flap  of  skin  lying  above  the  incision  between  the  incision  and  the 
eyebrow  is  undercut.  This  undercutting  is  continued  until  the  lid  margin  descends 
to  a  lower  level  than  normal. 

"A  mold  is  next  taken  of  this  cavity,  covered  with  skin-graft  in  the  same  way, 
and  the  skin  united  again  at  the  original  incision.  After  the  skin  is  thus  sewn  over 
the  mold  the  ectropion  is  more  pronounced  for  the  time  being  and  until  the  mold  is 
removed.  This  incision  is  not  tightly  closed,  so  that  there  are  one  or  two  gaps  in 
it  which  allow  the  new  epithelium  to  grow  around  the  margin  of  the  incision.  In 
some  of  the  cases  the  incision  is  reopened  and  the  mold  removed  on  the  tenth  day. 
The  lid  will  drop  below  the  normal  level,  and  the  ectropion  is  permanently  cured. 
In  other  cases  the  incision  is  allowed  to  open  gradually  of  its  own  accord,  until  there 
are  only  one  or  two  small  bridges  of  skin  holding  it  in  position.  These  can  easily 
be  cut." 

Pedunculsited  Flaps. — For  the  repair  of  displaced  eyelids  and  loss 
of  lid  substance  pedunculated  flaps  taken  from  the  temple  and  fore- 
head and  rotated  into  place  after  suitable  dissection  are  constantly 
utilized,  and  in  the  opinion  of  many  surgeons  the  flap  method  should 
generally  be  the  operation  of  election.  So  also  the  flap  may  be  cut 
from  the  cheek  and  slid  or  advanced  into  position  to  cover  the  raw 
surface  which  has  been  exposed  by  the  dissection  made  necessary  to 
return  the  displaced  lid  to  its  normal  relations.  Occasionally,  a 
pedunculated  flap  taken  from  the  cervical  region  has  been  employed 
to  restore  the  lower  lid  (Snydacker's  method). 

Naturally,  retractions  of  the  temporal  portions  of  the  lids  are  more 


676 


OPERATIONS 


easily  rcmodiod  than  thoso  of  the  nasal  aspect.  Rut  small  flaps  cut 
from  the  forehead  and  turned  down  to  correct  defects  near  the  inner 
canthus  can  be  utilized,  as  especially  recommended  by  T.  Harrison 
Butler. 

Space  does  not  permit  a  description  of  the  many  ingenious  plastic 
methods  devised  especially  during  the  recent  war.  Certain  general 
principles  ma}'  be  mentioned. 

The  exposed  raw  surface  should  be  carefully  measured  with  com- 
passes or  a  template  made  of  tinfoil  or  rubber  tissue,  to  guide  the  sur- 
geon in  marking  out  the  flap  which  is  to  be  rotated  or  advanced  into 
position.  This  flap  should  be  about  one-third  larger  in  all  directions 
than  the  defect  it  is  intended  to  cover,  its  pedicle  of  sufficient  size  to 
furnish  blood  supply  and  it  should  not  be  cut  too  thin.     Cicatricial 

tissue  nuist  be  entirely  removed  and 
cicatricial  bands  thoroughly  divided. 
Ligation  to  control  hemorrhage  should 
be  avoided;  during  operation  pres- 
sure and  artery  clamps  shoUkl  be  used 
to  control  bleeding,  and  the  vessels 
twisted  before  the  hemostats  are  re- 
moved. John  Wheeler  suggests  that 
a  small  gauze  drain,  to  remain  a  day 
or  two,  should  be  placed  at  or  near 
the  base  of  the  flap.  Sui)iK)rt  of  flaps 
in  order  to  avoid  tension  may  be 
secured  with  properly  placed  strips 
of  plaster,  and  Wheeler  employs  ail- 
hesive  strips,  ecjuipped  with  small 
hooks,  so  placed  that  the  proper  traction  will  be  produced  to  give  relaxa- 
tion to  the  flap.  A  rubber  band  is  strung  between  the  hooks  to 
produce  tension.  Although  skin  sutures  may  be  removed  in  four  to 
five  days,  this  relaxation  apparatus  should  remain  in  place  for  at 
least  ten  days  to  assure  strong  union,  with  the  eyelid  in  proper  jiosition 
(Fig.  302). 

In  a  certain  number  of  cases  a  cavity  is  iormcMl  ])ecause  there  has 
been  a  depressed  adherent  flap.  This  may  l)e  filled  in  with  fat  or 
muscle  before  the  flap  is  sutured  into  i)lace,  and  loss  of  a  portion  of  the 
orbital  margin  may  be  repaired  by  cartilage  grafts. 

Should  it  not  be  possible  to  cover  in  comjileteiy  the  defect  on  the 
temple,  cheek,  or  forehead  after  the  flap  has  been  rotated  into  place, 
the  defect  should  be  covered  with  a  \\'()ife  or  Thiersch  graft. 

Should  there  be  breaking  down  of  the  epithelium  of  the  flaps,  indi- 
cating necrosis  of  the  uppt-r  la>i'rs,  the  suggestion  of  (JilTord  to  scrape 
the  area  uiilil  healthy  bleeding  tissue  is  reached,  .uid  lh(>n  apply  a 
Thiersch  graft,  may  be  follnwed  with  advantage,  altluiugh  the  neces- 
sity for  this  is  more  likel\'  to  oceur  in  c;ises  in  which  a  ll;ip  without  a 
pedicle  has  been  transplanted  I  li.in  w  lieic  Haps  retain  li\iiiiiC(inn(>ct  ion 
with  the  surrounding  tissues. 


Fig.  302. — Support  of  flaps  as  uti- 
lized by  Dr.  John  Wheeler  (Archives 
of  Ophthalmology,  Vol.,  xlix,  p.  35). 


PEDUNCULATED    FLAPS 


677 


Figures  303  to  309  illustrate  a  few  of  the  well-known  procedures  of 
blepharo plasty.  Although  essentially  diagrammatic,  thej^  serve  a 
useful  purpose  in  that  they  show  some  of  the  methods  bj^  which  sliding 
flaps  may  be  formed  for  the  relief  of  deformities  of  the  lid.     But,  as 


Fig.  303.  Fig.  3U4. 

Figs.  303,  304. — Restoration  of  the  lower  lid  by  Dieffenbach's  method.  The  dis- 
eased or  scar  tissue  has  been  removed  in  a  triangular  flap,  a-b-c.  This  defect  is  covered 
by  a  flap  taken  from  the  cheek,  indicated  by  the  dotted  lines,  b—d-e,  with  the  result 
shown  in  Fig.  304.  The  remaining  gap  may  be  covered  .with  a  Thiersch  graft.  This 
operation  has  been  modified  by  several  surgeons  chiefly  in  the  formation  of  the  flap 
b~d-e,  so  that  the  secondary  defect  shall  be  smaller  and  the  pedicle  narrower,  allowing 
an  easier  rotation,  as  is  the  case  in  the  Arlt-Blaskovic  modification. 

before  noted,  successful  blepharoplasty  usualh'  cannot  be  secured  by 
means  of  a  named  operation,  which  may  well  be  a  guide,  but  only  by  a 


Fig.  305.  Fig.  306. 

Figs.  305,  306. — Restoration  of  lower  lid  by  Burow's  method.  The  diseased  tissue 
is  removed  with  the  flap  a-b-c.  The  horizontal  incision  is  prolonged  upon  the  temple 
and  forms  the  basis  of  the  triangle  a-d-^.  This  flap  {B)  being  removed,  the  cutaneous 
flap  a-c-d  is  dissected  up  and  drawn  inward  so  that  the  angle  a  is  sutured  at  the  point  h, 
and  a-d  forms  the  free  border  of  the  lid;  c-a  is  now  united  with  c-6,  and  d-e  with  a-e, 
with  the  result  shown  in  Fig.  306. 

careful  plan  of  action  according  to  the  condition  of  the  defect  and  that 
of  the  surrounding  tissue.     Prior  to  operation  the  skin  surface  should 


678 


OPERATIONS 


be  thoroughly  cleansed  with  soap  and  painted  in  the  usual  manner  with 
iodin.  During  the  procedure  the  field  of  operation  should  be  fre- 
quently irrigated  with  a  warm  sterile  phj-siologic  salt  solution.  After 
the  flaps  are  in  place  they  and  the  suture  hues  may  be  again  painted 
with  a  5  per  cent,  solution  of  iodin;  this  does  not  interfere  with 
their  vitality  (Morax).  A  dressing  of  rubber  protective  on  which 
layers  of  gauze  are  laid  is  not  satisfactory,  but  if  the  flap  is  first  smeared 


Fig.  307. — Restoration  of  the  upper  lid  by  iricke  s  method.  The  diseased  tissue 
has  been  removed  in  an  oval  flap.  The  resulting  gap  is  covered  by  a  similarly  shaped 
flap  taken  from  the  temple,  indicated  by  the  dotted  lie. 

with  sterile  vaselin  and  then  covered  with  thin  rubber  tissue  on  which 
is  placed  surgical  gauze  held  with  strips  of  plaster  and  over  this  cotton 
and  a  firm  pressure  bandage  the  results  are  good  (page  674).  A 
cellular  tissue  with  mesh  of  1  or  2  mm.  impregnated  with  a 
mixture  of  castor  oil  and  wax  and  sterilized  at  high  pressure,  known  as 


/~N 


Fig.  ;^()S.  Fig.  3i»y. 

Figs.  308,  309. —  Restoration  of  the  external  aii^le  of  the  lids  by  Unsner  d'Artha's 
method.  Tlie  diseased  tissue  is  removed  by  two  elliptic  incisions,  and  the  defect 
covered  with  a  flap  taken  from  the  temporal  region  at  h,  cut  in  the  manner  indicated 
by  the  dotted  line,  with  the  rtsvilt  shown  in  Fig.  309.  The  same  operation  applies  to 
the  inner  angle,  tlie  flap  being  taken  from  the  iK)Se. 

"greasy  tulle,"  is  highly  recommertded  by  jNIorax.  At  the  end  of 
seventy-two  hours,  should  there  be  any  (exfoliation  of  the  epiflicliiim, 
this  may  be  trimmed  away  and  the  edge  of  the  flaps  aiioinlcd  with 
White's  ointment  (page  727).  The  dressings  sngg(>st(Ml  may  be  us(»d 
also  for  protecliiig  a  wliole-skiii  noii-peduiiculalt'd  jl;ip  (see  page  (t7-0. 


SKIN    GRAFTING  679 

Whether  pedunculated  flaps  or  other  forms  of  skin-grafts  shall  be 
emploj^ed  must  be  decided  by  the  operating  surgeon,  according  to  his 
experience,  and  this  is  true  as  to  whether  a  Thiersch  or  a  Wolfe  graft 
shall  be  used.  The  author's  experience  and  observation  have  been 
most  favorable  to  the  various  methods  of  grafting,  not,  however,  to  the 
exclusion  of  pedunculated  flaps,  which  in  certain  cases  not  only  pro- 
duce the  desired  cosmetic  effect,  but  are  essential. 

Absence  of  the  action  of  the  elevator  of  the  lid  and  loss  of  the  Ud 
margin  of  the  upper  lid  present  complications  which  preclude  in  most 
instances  a  satisfa,ctory  result;  indeed,  in  these  circumstances  Gillies 
considers  operation  practically  useless,  that  is,  operation  on  the  lids 
and  orbital  socket,  and  he  doubts  if  a  strip  of  ej^ebrow,  although  it  has 
often  been  used,  constitutes  a  satisfactory  replacement  of  the  eye- 
lashes when  the  margin  of  the  upper  lid  has  been  lost.  Wheeler,  on 
the  other  hand,  reports  satisfactory  results  with  this  operation  and 
Morax,  in  the  event  of  one  eyebrow  being  destroyed  and  the  other 
brow  being  thick  enough,  detaches  half  its  breadth,  leaving  a  nasal 
pedicle,  and  fixates  the  flaps  thus  secured  in  an  incision  on  a  level  with 
the  upper  margin  of  the  orbit.  Should  both  ej-ebrows  be  lost  he  per- 
forms autoplast}'  without  a  pedicle,  the  flaps  being  taken  from  the 
occipital  region. 

Operation  of  Skin  Grafting. — If  the  portion  of  skin  removed  for  a 
graft  contains  only  the  epidermis,  rete  Malpighii  and  the  top  of  the 
papillary  layer  it  is  known  as  an  epidermic  graft;  if  the  entire  thickness 
of  the  skin  is  included  in  the  graft,  that  is,  the  whole  skin,  it  is  de- 
nominated dermic  graft  (also  Lefort-Wolfe  graft).  A  true  Thiersch 
graft  should  be  composed  only  of  the  epithelium  and  the  most  super- 
flcial  layer  of  the  cutis. 

To. remove  a  whole-skin  or  dermic  graft,  with  a  sharp  knife  the  surgeon  cuts 
just  through  the  skin  as  it  has  been  outhned,  slightly  undermines  the  edge  of  the 
flap,  and  proceeds  to  dissect  it  from  the  underlying  subcutaneous  tissue,  which  is, 
therefore,  not  included  in  the  graft.  Having  been  cleanly  removed  the  graft  is 
transferred  to  the  denuded  area.  Before  completing  the  dissection  fine  silk  sutures 
may  be  passed  through  the  undermined  edge  of  the  flap  which  facilitate,  after  the 
dissection  is  ended,  the  transfer  of  the  graft  to  the  area  to  be  covered  by  it  where 
they  are  utilized  to  fasten  it  into  proper  position.  The  grafts  may  be  taken 
from  the  inner  side  of  the  arm  or  thigh,  avoiding  hair\'  areas.  Sometimes  grafts 
are  secured  from  other  persons  (donors)  or  from  an  amputated  limb  possessing 
sound  skin. 

To  take  a  Thiersch  graft  the  skin,  preferably  on  the  inner  side  of  the  arm,  is 
stretched  flat  by  an  assistant  and  the  surgeon  with  a  long,  wide  razor  applied 
flat-wise  to  the  prepared  area  by  means  of  to-and-fro  movements  removes  the 
desired  tissue  which,  being  very  thin,  rolls  up  on  the  razor  from  which  it  may 
readily  be  transferred  directly  to  the  denuded  area.  Walter  Parker  recommends 
that  the  skin  surface  shall  be  greased  with  sterilized  vaselin,  which  greatly  facili- 
tates the  cutting  of  the  graft.  The  indications  for,  and  the  dressings  suited  to, 
skin-grafts  have  been  described. 

Operations  for  Prosthesis  in  Cases  of  Cicatricial  Orbital  Sockets.^ — 

Owing  to  the  formation  of  cicatricial  bands  and  scar  tissue  as  the 


680  OPERATIONS 

result  of  burns  (acids,  alkalis,  molten  metal),  injuries,  badly  performed 
enucleations,  trachomi,  etc.,  it  is  often  necessary  to  make  a  new  culde- 
sac  before  an  artificial  eye  can  be  adjusted.  Numerous  operations 
have  l)een  devised  lo  enlarge  the  socket  in  these  circumstances,  mere 
division  of  contracting  bands  being  entirely  insufficient.  It  would 
not  be  possible  in  a  chapter  of  such  limited  scope  as  the  present  one  to 
describe  the  many  ingenious  and  effective  procedures  which  have 
been  elaborated,  and  therefore  only  a  few  general  principles  and  one 
or  two  methods  can  be  recorded. 

In  general  terms,  the  new  culdesac  may  be  formed  by  pedunculateil 
flaps  from  skin  adjacent  to  the  orbit,  or  it  may  be  lined  by  transferred 
integument  (Wolfe  grafts),  or  by  Thiersch  grafts,  in  each  instance 
molded  in  place  after  suitable  dissection  by  means  of  various  con- 
formers. 

Esser's  Inlay. — Esser's  epithelial  inlay  may  be  used  to  enlarge  a 
contracted  lower  fornix,  not  an  uncommon  defect  which  prevents  the 
retention  of  an  aitificial  eve.     Gillies  describes  the  method  thus: 


"An  incision  is  made  from  the  outside  into  the  lower  lid  until  the  deep  surface  of 
the  conjunctiva  is  reached.  The  scar  tissue  which  is  found  in  this  situation,  due 
to  the  injury,  is  next  dissected  carefully  off  the  deep  surface  of  the  conjunctiva; 
some  sterilized  dental  composition  is  then  taken,  and  the  mold  of  this  cavity 
prepared.  The  skin  edges  are  drawn  together  over  the  mold  in  order  to  ascertain 
whether  it  is  of  the  right  size.  If  it  is  too  big,  it  is  cut  down  until  the  skin  eilges 
meet.  The  mold  is  now  taken  out  of  the  cavity  and  a  freslily  cut  Thiersch  graft 
from  the  inner  side  of  the  arm  is  wrapped  around  the  mold,  which  is  put  into  tiie 
cavity,  the  epithelial  surface  of  the  graft  being  toward  the  mold.  'J'he  skin  edges 
are  next  united  over  the  mold  and  skin-graft,  which  should  be  buried  for  ten  days. 

"At  the  end  of  this  time  an  incision  is  made  through  the  conjunctiva  at  tlie  spot 
where  the  scar  tissue  was  removed.  Immediately  underlying  the  conjunctiva  will 
be  found  the  .skin-graft,  and  next  to  it  the  mold.  One  ])lade  of  a  pair  of  scissors  is 
inserted  into  the  cavitj'  in  which  the  mold  is  lying,  and  the  incision  in  the  con- 
junctiva thus  widened  to  the  full  extent  c)f  the  size  of  the  moKl.  The  mold  can  be 
easily  removed,  and  it  will  be  found  that  the  cavity  in  which  it  is  lying  is  epithelial- 
ized  on  all  its  aspects,  and  the  oidy  raw  surface  to  contend  with  is  the  small  area 
lying  between  the  skin-graft  and  conjunctiva.  A  prosthetic  piece  should  be 
immediately  inserted  into  tlie  cavity  to  retain  its  size  and  shape  and  to  keej)  its 
opening  into  the  eye  socket  widely  j)atent.  This  is  of  great  imjjortance,  and  the 
nearer  the  inlay  is  j)ut  to  the  conjunctiva  in  the  first  instance,  the  less  raw  area 
there  is  to  heal  over."  A\'al(!nin  makes  the  j)rimary  incision  in  the  conjuiu-tiva 
and  after  suitable  undercutting  buries  the  graft-covered  moUl,  holding  it  in  place  by 
suturing  the  (■onjunctix  ;i  over  it. 

Lining  a  New  Culdesac  with  Epidermic  Graft.-  .V  contnicted  socket,  after  the 
new  culdesac  is  formed  by  suitable  dissect  iftn  and  freed  from  scar  tissue,  may  be  lined 
with  a  Thiersch  gr:ift,  wrapjied  around  (the  raw  surface  outward)  a  mold  of  dental 
modeling  comjjositicui,  or  "stent.  "  The  graft  must  be  somewhat  larger  than  the 
area  to  be  covered,  and  the  mold  of  stent  so  forn.ed  that  it  neatly  pres.ses  the  graft 
over  the  entir<'  surface  (»f  the  new  socket.  .Xfter  it  is  in  place  the  lids  should  be 
stitched  tcjgether,  and  should  not  be  disturbed  for  at  least  ten  d.-iys.  If  successful, 
after  removal  of  the  "stent  "  it  will  be  fouii<l  that  tin- graft  "h.-is  taken,"  and  covers 
the  desired  surface.  Kven  if  a  part  of  the  graft  is  lost,  a  .second  gnifting  over  the 
exposed  area  is  j)erfectly  feasible.  In  fome  cases  it  is  possible,  before  the  graft  is 
j)ut  in  j)lace,  to  introduce  a  piece  of  cartilage,  as  is  described  (page  711),  which 
fcunis  a  base  on  which  llic  ;irtifici;d  eve  rests. 


CONJUNCTIVOPLASTY 


681 


Weeks  restores  the  ciildesac  with  dermic  (Wolfe  grafts)  which  are 
secured  by  sutures  which  anchor  them  to  the  periosteum  and  emerge 
on  the  cheek.  He  insists  that  success  depends  on  attaching  the  im- 
planted flaps,  whatever  their  nature  may  be,  to  periosteal  or  epiperi- 
osteal  tissue  at  the  margins  of  the  orbit. 

Maxwell's  Method. — Restoration  of  the  lower  culdesac  may  be  secured  with 
Maxwell's  method,  wlio  operates  as  follows: 

"An  incision  is  made  in  the  floor  of  the  socket  and  carried  downward  behind  the 
lower  hd.  A  semilunar  flap  about  8  mm.  in  width  at  its  widest  part  is  marked  out 
on  the  skin,  its  upper  concave  border  being  about  5  mm.  below  the  edge  of  the 
lower  lid.  The  incision  along  the  upper  border  of  the  flap  is  made  to  communicate 
with  the  bottom  of  the  wound  in  the  socket.  The  flap  is  now  dissected  up  from 
the  subcutaneous  tissue,  except  an  area  represented  by  the  dotted  line  in  the  figure. 
The  two  ends  of  the  flap  (a'  and  b')  are  passed  through  the  opening  into  the  socket 


Fig.  310. — Maxwell's  operation  to  enlarge  a  contracted  socket. 
Review,"  Vol.  xxii.) 


("Ophthalmic 


and  sutured  to  each  end  of  the  socket  incision  (a  and  b),  and  the  borders  A'  and 
B'  being  also  passed  through,  are  sutured  to  A  and  B  respectively.  The  space  on 
the  cheek  is  closed  and  the  operation  completed  bj-  putting  in  a  temporary  glass  eye 
or  shell.  This  should  be  as  nearly  as  possible  of  the  size  and  shape  as  that  which  is 
to  be  ultimately  worn.  This  glass  eye  prevents  the  new  sulcus  from  being  oljliter- 
ated  by  contraction  and  gives  it  a  suitable  shape.  It  cannot  safely  be  taken  out 
for  at  least  a  week,  as  the  skin  incision  might  be  opened  in  so  doing.  If  there  be 
secretion,  the  space  behind  can  be  flushed  out  by  a  lacrimal  syringe  armed  with  a 
fine  curved  nozzle,  which  can  be  introduced  under  the  ej'e  at  the  inner  or  outer 
canthus.  A  glass  shell  with  a  hole  in  front  is  preferable  to  a  glass  eye,  because  it 
allows  a  syringe  to  be  more  easily  used,  and,  being  transparent,  a  view  of  the  part 
behind  can  be  obtained"  (Fig.  310). 

For  those  cases  where  the  socket,  although  shrunken,  retains  a  certain  amount  of 
conjunctiva,  Meyer  Wiener's  method  may  be  used,  which  consists,  by  suitable  dis- 
section, in  providing  a  conjunctival  covering  for  the  lower  lid,  leaving  the  bulbar 
surface  to  be  covered,  which  is  done  by  wrapping  a  previously  shaped  lead  plate 
with  epidermic  grafts  placed  in  proper  position.  To  restore  the  entire  orbital 
socket,  Schwenk  and  Posey  form  the  lower  culdesac  by  Maxwell's  method  and  the 
upper  one  by  transposing  a  long  flap  taken  from  the  skin  of  the  forehead  above  the 
brow. 

OPERATIONS  ON  THE  CONJUNCTIVA 

Conjunctivoplasty. — The  use  of  conjunctival  flaps  in  the  treatment 
of  spreading  ulcers  of  the  cornea,  after  abscission  of  prolapsed  iris, 
and  in  the  management  of  corneal  and  corneoscleral  wounds  has 


682 


OPERATIONS 


been  referred  to  in  the  sections  devoted  to  these  conditions.  It 
represents  a  surgical  procedure  of  great  value  and  its  good  results 
were  noteworthy  during  the  past  war.     The  technic  is  as  follows: 

If  the  wound  is  situated  peripheralh',  for  example,  at  the  corneoscleral  border, 
the  conjunctiva  is  incised  along  one-half  of  the  corresponding  circumference  of  the 


^^'^'''mm^' 


Fig.  312.— Flap  in  place. 
(After  Kuhnt,  "Medical  War 
Manual,"   Xo.  3,  Lea  &  Febigcr, 

1918.) 


Fig.  311. — By  passing  the  suture  through  a 
fold  in  flap  and  then  through  a  fold  above  a  firmer 
hold  can  be  obtained  and  the  anchoring  hold  should 
include  episcleral  tissue.  (After  Kuhnt,  "Medical 
War  Manual,"  No.  3,  Lea  &  Febiger,  1918.) 

cornea,  undermined  sufficiently,  and  drawn  across  the  cut  and  fastened  by  means 
of  two  sutures  placed  at  each  end  of  the  incision;  at  least  one-half  of  the  cornea 
can  be  covered  in  this  manner  (Fig.  312).     For  a  wound  crossing  the  cornea  almost 


'%J«#^" 


Fig.    313. —  Hridge.     (After    Kuhnt,  Fig.    314. —  Bridge    in    place. 

"Medical    War    Manual,"    No.    3,    Lea    &  (After     Kuhnt"     Mcdiial     War 

Febiger,  1918.)  Manual."    No.  3,  Leu  A-  IVbiger. 

1918.) 

entirely,  or  for  one  situated  quite  centrally,  it  is  more  expeilient  t«»  cover  the  defect 
by  means  of  a  bridge  of  conjunctiva.  To  form  it  one  cut  is  directly  circunuvuneal 
and  a  secoiul  one  placed  about  S  mm.  from  it.  The  piece  of  conjuiu-tiva  between 
these  two  incisions  is  drawn  over  the  injured  area  and  fasteneil  by  means  of  a 
suture  ai)Ove  and  below  (Fig.  314). 

In  gaping  wounds  across  the  cornea  it  may  br  nrces.'iary  to  cover  the  entire 
corneal  area  witii  conjiMictiNwi.      l'"or  this  purpose  the  conjunct i\!i  is  incis<'(l  around 


PTERYGIUM  683 

the  entire  circumference  of  the  cornea,  undermined  for  approximately  6  mm.,  and 
then  drawn  over  the  cornea  by  means  of  a  purse-string  suture  (de  Wecker),  or 
fastened  after  the  manner  of  Kuhnt  (Figs.  311,  314).  After  the  corneal  wound  has 
healed  the  conjunctival  covering  is  removed  and  restored  to  its  original  position. 
Even  if  a  wounded  eye  with  prolapse  of  the  iris  is  not  seen  until  there  is  incarcera- 
tion of  the  iris  in  the  wound,  the  prolapse,  if  no  infection  exists,  may  be  amputated 
in  the  usual  manner  and  the  opening  covered  with  a  conjunctival  flap. 

In  any  of  these  instances  should  no  inflammatory  reaction  appear  (iritis,  irido- 
cyclitis) within  a  few  days,  the  likelihood  of  its  manifestation  and  the  danger  of 
sj'mpathetic  ophthalmia  is  greatly  diminished.  If  such  complications  arise  in 
spite  of  conservative  surgery,  and  the  danger  of  sympathetic  ophthalmia  arises, 
radical  interference  is  promptly  indicated.  Fascia  lata  grafts  have  been  used  as  a 
substitute  for  conjunctivoplasty,  and  where  a  Kuhnt  graft  has  failed  of  its  purpose 
(I.  Whitaker). 

Operations  for  Pterygium.^ — (a)  Excision. — The  pterygium  is  seized  with  a 
toothed  forceps,  raised  from  the  surface  of  the  eye,  and  shaved  off  with  a  Beer's 
knife  from  its  corneal  attachment.  It  is  next  turned  backward,  carefully  dissected 
from  the  underlying  tissues,  and  excised,  together  with  a  triangular  piece  of  con- 
junctiva. This  leaves  a  somewhat  diamond-shaped  gaping  wound  in  the  conjunc- 
tiva, which  is  drawn  together  with  several  sutures.  If  the  conjunctiva  overlaps  the 
corneal  margin,  two  small  vertical  cuts  should  be  made  in  it  at  right  angles  to  the 
line  of  excision.  After  the  apex  of  the  pterygium  has  been  separated  from  the 
cornea,  the  vascular  subconjunctival  tissue  must  be  scraped  away  down  to  the 
sclera;  otherwise  there  will  be  reattachment.  The  suggestion  of  Prince  to  tear  loose 
the  pterygium  with  a  strabismus  hook  instead  of  separating  the  point  with  a  knife 
is  a  very  good  one.  Complete  excision  is  not  applicable  to  large  nor  to  fleshy 
pterygia. 

(6)  Transplantation  {Knapp's  Method). — This  consists  in  dividing  the  corneal 
attachment,  turning  the  pterygium  back,  and  splitting  it  from  apex  to  base.  The 
ends  are  then  cut  off,  and  each  flap  is  transplanted  into  its  corresponding  upper  and 
lower  conjunctival  wound,  and  fixed  in  position  with  fine  sutures.  The  exposed 
surface  of  the  sclera  is  covered  by  first  dissecting  up  and  then  drawing  together 
the  conjunctiva. 

Mc  Reynolds'  Operation. — This  operation,  which  is  a  modification  of  Desmarres' 
method,  gives  admirable  results,  and  in  the  majority  of  cases,  so  far  as  the  author's 
experience  is  concerned,  has  proved  by  far  the  most  satisfactory  one  in  this  affec- 
tion.    Dr.  McReynolds  describes  his  operation  in  the  following  words: 

"Grasp  completely  the  neck  of  the  pterygium  with  strong  but  narrow  fixation 
forceps.  Pass  a  Graefe  knife  through  the  constriction  and  as  close  to  the  globe  as 
possible,  and  then,  with  the  cutting  edge  turned  toward  the  cornea,  smoothly  shave 
off  every  particle  of  the  growth  from  the  cornea.  With  the  fixation  forceps  still 
hold  the  pterygium,  and  with  slender  straight  scissors  divide  the  conjunctiva  and 
subconjunctival  tissue  along  the  lower  margin  of  the  pterygium,  commencing  at  its 
neck  and  extending  toward  the  canthus,  a  distance  of  3^  to  3^  inch.  Still  hold  the 
pterygium  with  the  forceps,  and  separate  the  body  of  the  growth  from  the  sclera 
with  any  small,  non-cutting  instrument.  Kow  separate  well  from  the  sclera  the 
conjunctiva  lying  below  the  oblique  incision  made  with  scissors.  Take  a  black  silk 
thread,  armed  at  each  end  with  small  curved  needles,  and  carry  both  of  these 
needles  through  the  apex  of  the  pterygium  from  without  inward  and  separated  from 
each  other  by  a  sufficient  amount  of  the  growth  to  secure  a  firm  hold.  Then  carry 
these  cutting  needles  downward  beneath  the  loosened  conjunctiva  lying  below  the 
oblique  incision  made  by  the  scissors.  The  needles,  after  passing  in  parallel  direc- 
tions beneath  the  loosened  lower  segment  of  the  conjunctiva  until  they  reach  the 
region  of  the  lower  fornix,  should  emerge  from  beneath  the  conjunctiva  at  a  distance 
of  about  3^  to  3i  inch  from  each  other.  Isext,  with  the  forceps,  lift  up  the  loosened 
lower  segment  of  the  conjunctiva  and  gently  exert  traction  upon  the  free  ends  of 
the  threads  which  have  emerged  from  below,  and  the  pterygium  will  glide  beneath 
the  loosened  lower  segment  of  the  conjunctiva,  and  the  threads  may  now  be  tight- 
ened and  tied  and  the  surplus  portion  of  the  thread  cut  off,  leaving  enough  to 


684 


OPERATIONS 


facilitate  the  removal  of  the  threads  after  proper  union  has  occurred.  It  is  ex- 
tremely important  that  no  inci.sion  be  made  along  the  upper  border  of  the  ptery- 
gium; othcrwifse  it  would  gape  and  would  leave  a  denuded  space  when  downward 
traction  is  made  upon  the  pterygium." 

The  return  of  a  pterygium  after  excision  is  not  uncommon;  occa- 
sionally the  second  growth  is  thicker  than  the  primary  one,  and  may 
exceptionally  assume  a  species  of  keloid  formation.  After  Mclley- 
nolds'  transplantation  operation  the  author  has  observed  no  recur- 
rences, nor  the  formation  of  c^'Sts. 


Fig.  '.ilij. — -McReyuolds'  operation  fur  pterj-Kiuiii:  A,  Showing  needles  1  and  2, 
which  enter  the  neck  of  the  pterygium  p  t  c  at  a  and  /»,  and  then  pass  beneath  the  loosened 
lower  segment  of  conjunctiva  x  y  z,  and  then  emerge  at  c  and  d  helow  the  cornea;  B, 
showing  pterygium  p  (  c  fixed  by  a  single  stitch  c  d  beneath  the  loosened  lower  segment 
of  conjunctiva  x  y  z,  wliile  tlie  former  side  of  the  growth  p  x  t  is  covered  by[the  norma 
smooth,  stretched,  and  thinncd-out  conjunctiva  p  .r  I. 

Operations  for  Symblepharon. — An  atttMnpt  may  he  made  to 
remedy  tliis  condition  \)y  dixidiiiji"  the  adhesion  ami  uniting  the  cut 
edges  of  the  conjunctiva  with  sutures,  or  covering  the  raw  sin-face  left 
after  severing  the  adhesions  with  flaps  of  healthy  conjunctiva  taken 
from  the  unaffected  parts  of  the  eyeball  {Teak's  operation),  or  l)y  dis- 
secting back  the  synd)lephar()n  as  far  as  the  retrotarsal  fold,  doubling 
it  upon  its(!lf  so  as  to  ojjposc  a  nuicous  siu'face  to  tlu>  globe,  and  fixing 
it  in  this  position  by  means  of  a  ligtiture  which  is  armed  with  two 
needles  and  passed  though  the  lid  from  the  coiijniict iv;i  onward. 

Transplantation  of  Mucous  Membrane  and  of  Thiersch's  Grafts. 
In  cas(;s  of  exteiisivt;  adhesion  beweeii  the  ball   and  the  Uds  tlie  Iraiis- 
phiiitatioM  of  rabbit's  eoiijiiiict  iva  has  been  attempted. 

In  lliis  operation,  after  the  adhesions  h;ive  been  se\-ered,  the  law 
snrfaees  are  eoxcicd  with  ;i  li;ip  of  corijnneliva  taken  from   -a  rabbit's 


li 


OPERATIONS  FOR  TRACHOMA 


685 


eye,  so  removed  as  to  be  free  from  all  submucous  tissue,  and  somewhat 
larger  than  the  defect  which  it  is  expected  to  cover.  It  is  better  to 
insert  the  sutures,  with  which  it  is  afterward  put  in  place,  before  its 
removal,  as  they  mark  the  position  of  the  flap,  and  at  the  same  time 
give  a  means  by  which  it  may  be  transferred  from  the  eye  of  the  rabbit 
to  the  eye  of  the  patient.  It  must  be  kept  warm  and  moist  during  the 
process  of  transferring  it.  All  bleeding  must  be  stopped  before  the 
attachment  is  made.  Instead  of  utilizing  the  conjunctiva  from  a 
rabbit's  ej^e,  mucous  membrane  may  be  taken  from  the  lip  or  inner 
surface  of  the  cheek  of  the  patient.  In  the  experience  of  the  author 
transplantation  of  mucous  membrane  is  usually  an  unsatisfactory 
procedure;  but  G.  B.  Jobson  prefers  mucous  to  dermic  grafts  in  exten- 
sive posterior  sjmiblepharon  and  total  symblepharon  of  the  lower  lid 
and  has  devised  a  satisfactory  technic.^ 


Fig.  316. — Teale's  operation  for  symblepharon  (figures  from  Swanzy).  The  sym- 
blepharon is  detached  at  A  and  removed.  Two  conjunctival  flaps,  B  and  C.  are  formed 
and  turned  to  cover  the  denuded  surface  of  the  eyeball  and  of  the  inner  side  of  the  lid. 
The  conjunctival  gaps  are  closed  by  sutures,  D  and  E. 

Thiersch  grafts  maj^  be  utilized  for  this  purpose,  which  are  cut 
in  the  manner  alread}'  described  on  page  679,  and  which  were  spe- 
cially recommended  b}-  Hotz,  and  which  the  author  has  used  with 
the  greatest  satisfaction.  The  adhesions  between  the  lid  and 
globe  are  separated  in  the  usual  manner,  and  after  all  bleeding  has 
stopped  the  Thiersch  graft  is  put  into  position.  One  difficult}-  is 
encountered,  namely,  the  movement  of  the  lid  is  apt  to  displace  the 
graft,  especially  if  the  denuded  area  is  a  large  one,  and  therefore  the 
transplanted  skin  should  be  secured  by  means  of  a  rigid  support  best 
secured  b}-  means  of  a  thin  mold  of  dental  modeling  composition. 

Operations  for  Trachoma. — On  page  240  the  operative  proced- 
ures suited  to  cases  of  trachoma  are  briefl}'  described.  Three  methods 
require  more  extended  notice : 

1  Trans.  Amer.  Academy  of  Ophthalmology  and  Otolan,-ngology,  1919,  p.  166. 


686 


OPERATIONS 


Expression  (Knapp's  Operation). — .After  the  patient  is  etherized  the  upper  lid 
is  everted,  seized  at  the  convex  border  of  the  tarsus  with  a  pair  of  fixation  forceps, 
and  drawn  away  from  the  eye  so  as  to  expose  thoroughly  the  whole  palpebrobulbar 
conjunctiva.  If  the  tissue  is  infiltrated,  it  may  be  superficially  scarified,  preferably 
with  a  three-bladed  scarifier  (Fig.  317).  One  blade  of  the  roller  forceps  is  pushed 
deeply  between  the  ocular  and  palpebral  conjunctiva,  and  the  other  is  applied  to  the 
everted  surface  of  the  tarsus.  The  forceps  is  compressed  with  some  force,  drawn 
forward,  and  the  infiltrated  soft  substance  squeezed  out  as  the  cylinders  roll  over 
the  surfaces  of  the  fold  held  between  it.  This  maneuver  is  repeated  until  all  the 
morbid  material  has  been  expressed — in  other  words,  to  use  Knapp's  expression. 


I'lG.   317. — Three-bladed  scarifier. 

until  the  conjunctiva  has  been  thoroughly  milked.  The  lower  lid  is  treated  in  the 
same  way.  During  the  operation  the  surfaces  should  be  frequently  flooilcd  with  a 
tepid  solution  of  bichlorid  of  mercur>',  1  :  8000,  and  after  the  operation  cold  com- 
presses may  be  laid  on  the  lid  for  twenty-four  hours. 

The  following  day  the  lids  should  be  everted,  and  usually  a  delicate  grayish 
layer  of  lymph  will  be  found  covering  the  entire  area  of  operation.  This  should  be 
removed,  the  swollen  mucous  membrane  exposed,  and  touched  in  the  ordinary  way 
with  a  solution  of  nitrate  of  silver,  5  to  10  grains  (0.324-0.650  gm.)  to  the  ounce 
(30  c.c).  Each  day  this  treatment  should  be  repeated  until  the  swelling  has  sub- 
sided, when  the  daily  application  of  a  crystal  of  sulphate  of  copper  is  advisable. 


Fig.   31S.       iMNijip's  opi'ialinn  Im-  tiMchoina  ^llaliSi-ll  iilid  Swoot). 

Th(3  oporation  should  he  done  thoidUf>;hly,  care  being  taken  to 
iiieludo  tlie  coinniis.suial  })ortion.s  of  the  eonjiinetiva,  and  the  .>^ul).se-- 
qiient  local  trealnicnl  of  (lie  case  must  not  he  neglected.  I-Ajjression 
is  especially  valuahle  in  cases  of  spawn-like  granulations  (follicular 
Irachonia)  and  dilTuse  hyaline  infiltration.  It  may  be  used  in  oicatri- 
cial  liachoma  when  patches  of  hyaline  tlegenerat  ion  are  present.  If 
the  patient,  suffers  a  relapse,  as  he  may,  the  operation  should  lu'  rv- 


OPERATIONS  FOR  TRACHOMA  687 

peated.  In  a  somewhat  extended  experience  the  author  has  never  seen 
any  save  good  results  from  this  method  of  treating  trachoma.  It  should 
never  be  used  in  so-called  acute  trachoma.  Some  surgeons  consider  the 
operation  more  effective  if  after  the  expression  a  germicide  is  brushed 
into  the  tissues. 

Modified  Brossage. — In  place  of  the  operation  just  described  the 
technic  advised  by  Surgeon  John  McMullen  of  the  United  States 
Public  Health  Service  may  be  adopted: 

"The  ej'elid  is  everted  by  means  of  a  special  forceps.  Next  by  the  use  of  two 
scalpels,  one  in  each  hand,  the  conjunctiva  is  graduallj^  raised  and  the  full  extent 
of  the  culdesac  is  exposed  and  the  granulations  are  scarified  superficially,  beginning 
from  the  bottom  and  extending  forward  toward  the  ciliarA^  margin.  Succeeding 
this,  in  some  cases,  it  is  well  to  use  a  moderately  stiff  brush  with  bichlorid  solution 

1  :  2000.  The  next  step  is  to  use  fine  mesh  gauze  sponges,  and  these  are  rubbed 
over  the  entire  affected  conjunctiva  until  the  surface  is  smooth  and  the  hypertrophj- 
and  granulations  have  been  removed.  This  can  be  determined  by  the  reappear- 
ance of  the  small  blood-vessels  to  view.  The  operation  is  completed  by  again 
everting  the  ej'elid  and  thoroughh'  washing  all  blood-clots  out  of  the  conjunctiva, 
etc.,  with  a  boric  acid  solution,  followed  by  the  instillation  of  2  drops  of  a  20  per 
cent,  solution  of  argyrol.  The  after-treatment  consists  in  cleansing  the  eyes  every 
three  hours  with  a  boric  solution  and  the  instillation  of  a  20  per  cent,  argyrol 
solution.     This  is  continued  for  several  days,  or  until  all  sloughs  have  disappeared." 

If  a  radical  operation  has  been  performed  the  eyes  should  be  examined  carefully 
for  the  next  twenty-four  to  forty-eight  hours  for  adhesions,  and  these  should  be 
broken  up  immediately.  At  the  end  of  about  one  week  following  operation,  if 
granulations  or  rough  surfaces  are  found,  these  should  be  lightly  touched  with  a 

2  per  cent,  solution  of  silver  nitrate,  repeated  two,  three,  four,  or  mores  times  a 
week.  " 

Grattage  with  the  aid  of  a  tooth  brush,  carrying  a  solution  of 
bichlorid  of  mercury,  that  is,  scrubbing  the  affected  conjunctiva,  is  an 
operation  which  does  not  appeal  to  the  author. 

Simple  Excision  of  the  Retrotarsal  Fold. — A  subconjunctival  injection  of 
cocain  (4  per  cent.)  causes  the  diseased  transition  fold  of  the  conjunctiva  to  bulge 
forward,  and  makes  plain  a  line  of  demarcation  between  the  diseased  area  and  the 
healthy  bulbar  conjunctiva.  The  convex  margin  of  the  tarsus  is  brought  within 
the  grasp  of  two  pairs  of  forceps,  and  an  incision  is  made  in  the  healthy  scleral 
conjunctiva  close  to  the  line  of  demarcation  from  the  outer  to  the  inner  canthus. 
Muller's  muscle,  which  has  a  bluish  look,  is  usually  recognized  when  the  wound 
separates  and  the  bulbar  conjunctiva  retracts.  Next,  three  sutures  are  introduced 
through  the  margin  of  the  bulbar  conjunctiva,  which  is  undermined.  The  next 
incision  is  so  placed  as  to  separate  the  transitional  fold  from  the  tarsus;  the  diseased 
tissue  lying  between  these  two  incisions,  being  seized  at  the  inner  canthus,  is 
separated  from  the  underlying  tissue  with  blunt  scissors  and  removed.  Finallj-, 
the  needles  attached  to  the  sutures  already  in  place  are  placed  through  the  edge  of 
the  tarsus  and  tied. 

Should  the  lower  fornix  be  selected  for  this  operation,  the  upper  lid  is  held  back 
and  the  patient  required  to  look  upward.  Next,  the  surgeon  everts  the  lower  lid 
and  excises  the  required  strip  of  conjunctiva.  Sutures  are  rareh*  necessar}-.  In 
both  instances  following  the  operation  the  eyes  should  be  freely  irrigated  with  a 
saturated  boric  acid  solution  or  one  of  bichlorid  of  mercurj-  (1  :  8000),  and  the 
operated  area  dusted  with  finely  powdered  iodoform,  following  which  a  fight  com- 
pressing bandage  should  be  applied. 

This  operation  is  suitable  if  the  trachomatous  process  is  largely  confined  to  the 


688 


OPERATIONS 


transition  fold,  and  there  is  no  serious  lyniplioid  infiltration  of  the  tarsus  itself. 
It  is  also  sometimes  effective  in  checking  a  developing  pannus. 

Combined  Excision. — After  free  cocainization,  the  eye  being  rotated  down- 
ward, the  ui>])er  lid  is  doubly  everted  and  held  in  position  by  means  of  two  fixation 


Fig.  319. — C"oml)iiiod  excision  in  tra- 
choma: First,  stage.  (Woottou,  Archives  of 
Ophthalmology,  Vol.  xxxix,  p.  110.) 


Fig.  320. — Combined  excision  in  tra- 
choma: Second  stage.  (Wootton,  .\rch- 
ives  of  Ophthalmologv,  Vol.  xxxix,  p. 
110.) 


forceps,  in  such  a  manner  that  the  bulbar  con- 
junctiva is  drawn  upward  upon  the  surface  of  the 
tarsus.  The  first  incision,  which  should  penetrate 
the  conjunctiva  alone,  is  made  transversely  at  the 
juncture  of  the  palpebral  and  bulbar  conjunctiva 
(Fig.  319),  thus  separating  the  diseased  and  healthy 
tissue.  Injury  of  Miiller's  nuisde,  which  lies  di- 
rectly beneath,  must  be  avoided.  The  retracted 
bulbar  conjunctiva  is  next  separated  from  the 
sul)jacent  tissue  for  a  distance  of  4  mm.  Three 
sutures  armed  with  a  needle  ateacheml  are  in.serted 
llirough  the  lower  lip  of  the  wound.  Following 
t  liis  dissection  the  lid  is  allowed  to  take  the  position 
of  single  eversion,  and  a  horn  or  .I;ieger  plate  is 
|)laced  l)eneatli  the  cutaneous  surface  of  the  eyelid, 
the  margin  of  which  is  pressed  firmly  upon  it 
(I''ig.  320).  Next  an  incision  is  made  for  the  entire 
length  of  the  lid  2.')  mm.  from  its  inm-r  margin  and 
ex.ictly  |)arallel  to  it.  The  lateral  horns  of  the  two 
incisions  are  joined  by  a  short  vertical  cut  at  their 
<x(ernal  and  internal  extremities.  Thus  the 
boundaries  (tf  the  di.seased  conjunctiva  and  tarsus 
an-  fixed.  The  next  step  consists  in  di.s.secting  up 
this  area,  care  being  taken  not  to  inj\ire  the  or- 
bicularis or  Miiller's  nuisde.  How  nuich  of  the 
diseased  tarsus  sliall  be  removed  depends  upon  the  severity  of  the  condition  and 
the  distribution  i>l  the  lesions;  usually  the  pi«'ce  lemoved  is  about  '2J)  cm. 
long    and     1     cm.    broad.      Hemorrhage    liavuig    been    <liccl>,t'(l.    the    oper.'ition    is 


J''iG.  .321 . —  ( 'oiiiiiitieiJ  excision 
in  Irachoma:  Placing  the suttiies. 
(Wootton,  Archives  of  Oplillmi- 
mology,  Vol.  xxxix,  p.   IKt.) 


PARACENTESIS    CORNE.E  689 

completed  by  stitching  the  margin  of  the  bulbar  conjunctiva  to  the  rim  of  tarsus 
which  remains,  and  it  is  important  that  the  conjunctiva  shall  be  united  exactly 
to  corresponding  points  of  the  tarsal  cartilage.  The  eye  is  closed  and  the  surgeon 
makes  gentle  traction  on  the  middle  suture  in  a  direction  vertical  to  the  hd 
margin.  The  point  where  the  suture  crosses  the  upper  margin  of  the  tarsal 
rim  is  grasped  with  toothed  forceps,  one  blade  being  passed  beneath  the  lid,  which 
is  then  everted.  The  suture  is  next  passed  through  the  upper  margin  of  the 
tarsal  cartilage  at  the  point  designated  by  the  teeth  of  the  forceps.  The  other 
sutures  are  treated  in  like  manner  (Fig.  321).  In  order  to  avoid  pressure  on  the 
cornea  the  sutures  may  be  placed  thus,  following  the  method  of  von  Blacowicz. 
The  sutures  are  armed  with  two  needles,  which  are  passed  entirely  through  the  Ud, 
the  anterior  one  transfixing  the  upper  margin  of  the  cartilage,  the  posterior  one  the 
aponeurosis,  muscle  and  skin  in  close  proximity.  The  sutures  are  tied  over  a  roll 
of  gauze,  and  may  be  removed  on  the  fifth  day. 

This  mucotarsal  excision  is  recommended  for  chronic  trachoma  with  tarsal  in- 
filtration, chronic  trachoma  with  pannus  independently  of  the  tarsal  condition, 
and  in  gelatinous    trachoma  of  the  retrotarsal  folds  and  thickening  of  the  tarsus. 

In  cases  of  chronic  trachoma,  associated  with  great  infiltration  and 
thickening  of  the  tarsus,  Kuhnt  recommends  extirpation  of  the  tarsus 
with  excision  of  the  conjunctiva.  With  this  operation  the  author  has 
•had  no  experience. 

Subconjunctival  Injections. — The  eye  is  thoroughly  cleansed  and  anesthetized 
by  the  instillation  of  a  4  per  cent,  solution  of  cocain.  The  patient  is  required  to 
look  strongly  downward  and  inward  in  order  to  expose  the  supero-external  portion 
of  the  eyeball.  Next,  the  needle  of  a  hypodermic  or  Pravaz  syringe,  properly  steril- 
ized and  charged  with  the  fluid,  is  introduced  ver>'  much  in  the  same  manner  as 
when  an  ordinary  hypodermic  injection  is  given,  well  beneath  the  conjunctiva  and 
away  from  the  cornea.  The  quantity  to  be  injected  depends  upon  the  nature  of  the 
case  and  the  character  of  the  fluid  employed.  If,  for  example,  bichlorid  of  mercury 
is  used  in  a  strength  of  1  :  1000,  each  division  of  a  Pravaz  syringe  would  contain 
}io  mg.  of  the  drug.  Ordinarily,  a  solution  of  bichlorid  of  mercury,  1  :  2000  or 
4000,  maybe  used,  and  from  4  to  8  minims  (0.24  to  0.50  c.c.)  injected.  Generally, 
cyanid  of  mercury  is  the  preferable  drug,  and  maj^  be  used  in  a  strength  of  1  :  2000 
to  5000.  The  injection  may  be  rendered  practically  painless  by  adding  a  few  drops 
of  a  1  per  cent,  acoin  solution  to  the  fluid.  Darier's  directions  are  to  add  one-third 
of  a  syringeful  of  a  1  per  cent,  solution  of  acoin  to  two-thirds  of  a  syringeful  of 
cyanid  of  mercury,  1  :  1000,  and,  therefore,  obtain  a  solution  of  1  :  1500.  Physio- 
logic salt  solution  is  efficient  and  much  less  painful.  From  15  to  25  minims  (0.92- 
1.54  c.c.)  may  be  injected.  If  stronger  solutions  of  salt  are  used,  acoin  may  be 
added.  Solutions  of  hetol  (cynamic  acid)  in  1  per  cent,  strength  have  been  advised 
by  Pfliiger.  Subconjunctival  injections  of  guaiacol  cacodylate  are  recommended 
in  tuberculous  sclerokeratitis  and  uveitis  (Torok,  Darier). 

The  indications  for  these  injections  have  been  given  in  connection 
with  the  diseases  for  the  relief  of  which  they  have  been  recommended^ 
and,  in  the  experience  of  the  author,  they  are  sometimes  useful,  par- 
ticularly in  various  inflammations  of  the  uveal  tract,  the  sclera,  and 
some  types  of  parenchymatous,  as  well  as  ulcerated,  keratitis.  Their 
value  in  detachment  of  the  retina,  especially  solutions  of  salt,  has 
been  described  (see  page  494). 

OPERATIONS  ON  THE  CORNEA 

Paracentesis  Corneae. — The  local  application  of  cocain  is  usually 
sufficient,  but  in  nervous  subjects  and  young  children  general  anesthesia 
may  be  necessary.     The  operation  is  performed  as  follows : 


690 


OPERATIONS 


The  cornea  is  punctured  near  it.s  lower  niarnin  or,  in  the  ca^e  of  an  ulcer,  through 
its  floor  with  a  paracentesis  needle  constructed  with  a  shoulder  to  prevent  an  undue 
depth  of  entrance,  and  inserted  at  an  angle  of  4o°  with  the  point  of  contact ;  or  with 
a  broad  needle  held  flatwise,  the  point  being  kept  well  forward  so  as  to  avoid 
wounding  the  lens.  Hy  rotating  the  needle  slightly  on  its  long  axis  the  lips  of  the 
opening  are  separated  and  the  contents  of  the  aqueous  chamber  more  readily 
escape.     The  needle  must  be  withdrawn  slowly,  lest  a  sudden  gush  of  aqueous  cause 


Fig.  322. — Paracentesis  needle, 

prolapse  of  the  iris.  The  ej-eball  may  be  steadied  with  a  spring  speculum  (see 
Fig.  324)  or  fixation  forceps  (see  Fig.  325),  provided  the  former  does  not  put  too 
much  pressure  on  the  globe,  or  the  lids  may  be  separated  by  the  surgeon's  fingers. 
If  it  is  necessarj'  to  reopen  the  wound,  the  probe  end  of  the  instmment  should  be 
used. 


Application  of  the  Actual  Cautery. — The  indication.s  for  this 
application  in  corneal  disease  are  given  on  page  273.  If  possible,  a  suit- 
able galvanocautery  should  be  employed.  If  this  is  not  at  hand,  a 
platinum  probe  fixed  in  a  handle  similar  to  the  one  which  is  attached  to 
a  laryngoscope  mirror  will  suffice.     The  operation  is  done  as  follows: 

A  few  drops  of  cocain  or  holocain  solution  are  in.stilled  to  produce  anesthesia, 
and  the  probe  or  the  point  of  the  cautery  is  brought  to  a  red  heat,  transferred  to  the 
area  of  disease,  and  all  the  sloughing  material,  and  particularly  the  edge  of  the  ulcer, 
is  gently  but  thoroughly  cauterized.  It  is  not  necessary  to  bum  beyond  the  edge 
of  the  ulcer  into  sound  tissue.  The  extent  of  the  ulcerated  area,  even  to  the  finest 
spot  characterized  by  loss  of  epithelium,  may  be  ascertained  by  the  use  of  fluores- 
cein, but  it  should  be  remembered  that  this  drug  also  colors,  but  less  vividly, 
diseased  epithelium,  and  hence  is  apt  to  stain  the  epithelium  for  some  distance 
surrounding  the  ulcer.  Ulcers  with  much  necrotic  tissue  on  them  stain  yellow. 
The  separation  of  the  lids  with  a  stop  speculum  is  needless;  in  fact,  this  is  di.sadvan- 
tageous  on  account  of  the  pressure  it  exerts  upon  the  eyeball.  They  may  be  parted 
by  the  hands  of  the  operator  himself.  After  the  operation  the  eye  may  be  washed 
out  with  boric  acid  .solution,  a  drop  of  atropin  instilled,  luid  a  bandage  applied 
see  also  page  273). 

Quthrie=Saemisch  Section. — The  upper  lid  being  raised  on  an 
elevator  by  an  assistant,  the  surgeon  proceeds  as  follows: 

Tlie  conjunctiva  l)elow  the  cornea  is  seized  with  fixation  forceps,  a  cataract 
knife  is  entered  on  one  side  of  the  cornea,  carried  acro.ss  the  anterior  chamber  to 
the  other  side  of  the  ulcer,  and  the  section  made  with  its  cutting-edge  forward, 
directly  through  the  diseased  area,  evacuating  the  collection  of  pus  in  the  layers  «»f 
the  cornea  and  at  the  bottom  of  the  anterior  chamber.  If  the  hypojjvon  is  tena- 
cious, this  may  be  removed  by  inserting  a  ilelicate  pair  of  forceps  through  the  in- 
cision and  seizing  the  slough,  or  it  may  !)e  washed  out  with  !i  specially  devi.sed 
syringe.  If  the  pus  reaccumulates,  the  wound  should  be  reopeiu-tl  with  a  pitibe 
and  the  contents  of  the  anterior  cliamber  again  evacuated.  Schw«'nk  has  modi- 
fied this  operation  in  that  after  |)unctiire  and  counter  punctun-  are  made,  he 
presses  the  knife  backward  to  ecpialize  tiie  tension  and  by  rotating  it  on  its 
long  axis  creates  a  gaj)  at  its  jxiint  of  entrance  and  exit  through  which  the  lluiiis 
<lrain  and  gradually  release  the  tensi(ui;  fin.nlly,  the  knife  edge  lu-ing  turned  forward, 
the  iiicision  is  slowly  coiiiplctcd  in  the  ordinary  m.-mncr. 


OPERATIONS  FOR  STAPHYLOMA  691 

A  great  objection  to  this  operation  is  the  danger  of  prolapse  of  the 
iris,  which,  however,  is  said  to  be  pervented  by  Schwenk's  technic; 
indeed,  owing  to  the  improvement  in  the  treatment  of  hypopyon- 
keratitis  by  means  of  various  local  measures,  thermotherapy  and  bac- 
terins  (see  page  275)  the  operation  is  much  less  rarely  performed  than 
in  former  times.  As  a  rare  comphcation  intra-ocular  hemorrhage  has 
been  reported  (A.  W.  Sichel). 

Operations  for  Staphyloma. — If  the  measures  used  to  prevent 
the  formation  of  staphyloma  have  been  unsuccessful  (see  pages  274 
and  281),  an  operation  must  be  done  for  its  relief.  In  partial  staphy- 
loma vision  may  sometimes  be  improved  by  iridectomy,  and  even  by  a 
double  excision  of  the  iris,  but  very  often  these  measures  fail,  and  then 
its  removal  may  be  necessary. 

A  useful  operation  for  the  reduction  of  the  size  of  a  partial  staphy- 
loma is  recommended  by  Berry: 

A  cataract  needle  is  introduced  through  the  base  of  the  staphyloma  and  held 
in  one  hand.  An  eUiptic  piece  of  the  cicatricial  tissue  of  which  the  staphyloma  is 
composed  is  next  cut  out  by  making  one  incision  at  one  side  of  the  needle  with  a 
cataract  knife,  and  another  from  the  other  side,  converging  toward  the  first,  and  in 
such  a  manner  that  the  portion  held  by  the  needle,  and  consequently  the  needle 
itself,  is  cut  out.  The  dressing  consists  of  a  firmly  applied  antiseptic  bandage,  and 
usually  it  is  necessary  to  continue  the  bandage  for  some  time  until  flattening  of  the 
mass  has  been  secured. 

After  excision  of  a  small  staphyloma  it  is  sometimes  possible  to  promote  healing 
by  uniting  the  resulting  wound  margins  with  fine  silk  sutures  or  better  by  conjunc- 
tivoplasty  (page  681). 

S.  Lewis  Ziegler's  Trefoil  or  Stellate  Keratectomy  for  the  Relief  of  Anterior 
Staphyloma. — It  may  be  performed  with*  a  punch,  thus:  A  vertical  incision  is 
made  through  the  base  of  the  staphyloma,  and  the  inferior  blade  of  a  punch  is 
passed  into  the  anterior  chamber  and  beneath  the  cornea.  The  punch  is  closed 
and  the  left  lateral  flap  is  excised,  and  in  similar  manner  the  right  lateral  flap  is 
removed.  Next  the  upper  margin  of  the  oval  wound  is  grasped  at  its  center  by 
the  punch  and  a  vertical  piece  excised.     The  trefoil  opening  is  closed  with  sutures. 

De  Wecker's  Method. — This  is  suited  to  complete  staphyloma 
limited  to  the  cornea. 

Four  sutures  should  be  inserted  in  the  conjunctiva  after  it  has  first  been  care- 
fully detached  from  the  corneal  margin  almost  as  far  as  the  equator  of  the  eye.  In 
order  to  avoid  confusion  at  the  moment  of  tightening  the  threads,  the  precaution 
should  be  taken  of  having  them  of  different  colors.  The  removal  of  the  staphyloma 
is  performed  by  transfixing  it  through  the  middle  and  cutting  outward,  then  seizing 
the  end  of  the  flap  thus  formed,  and  removing  the  rest  with  scissors.  Care  must  be 
taken  that  the  lens  escapes  from  the  eye.  When  this  is  ascertained,  the  sutures 
in  the  conjunctiva  are  tightened  and  the  conjunctiva  drawn  over  the  wound. 

In  most  instances  of  complete  staphyloma,  with  participation  of  the 
sclera,  the  best  operation  is  enucleation  or  one  of  its  substitutes. 

Tattooing  the  Cornea. — In  order  to  conceal  the  disfigurement 
of  a  dense  leukoma  it  has  been  suggested  to  tattoo  the  white  tissue. 
This  is  done  as  follows: 


692 


OPERATIONS 


India-ink  rubbed  up  with  water  into  a  fine  paste  is  placed  close  at  hand.  After 
the  cornea  is  rendered  anesrthetic  witli  cocain,  the  ej'e  is  steadied  with  the  fingers, 
and  a  drop  of  the  pigment  is  applied  to  the  surface  of  the  leukoma,  and  the  ink 
pricked  into  place  with  the  needles.  These  needles  may  be  fixed  exactly  at  the 
same  level,  precisely  as  if  they  were  all  fastened  into  a  small  circular  piece  of  cork, 
or  they  may  be  phiced  side  by  side  (Fig.  323).  Finally,  a  single  needle,  somewhat  of 
the  type  of  an  ordinary  cataract  needle,  may  be  emploj'ed,  and  the  pigment  pricked 
into  the  tissue  with  little  stabs  n.ade  in  an  oblique  direction.  According  to  the  late 
Dr.  Noj'es,  the  pigment  should  be  prepared  by  allowing  the  India-ink  stick  to  soak 
for  several  hours  in  water  until  it  becomes  of  the  consistence  of  thick  paste.  A 
piece  of  pa.«te  equal  to  the  size  of  the  spot  to  be  colored  is  then  placed  upon  the 


III 


Fig.  32.J. — Tattooing  needle. 

leukomatous  area  and  pricked  into  position  with  the  needles.  The  tattooing 
should  proceed  until  a  uniform  black  surface  is  secured.  The  excess  of  pigment 
can  be  flooded  away  with  a  saturated  solution  of  boric  acid.  It  has  been  suggested 
by  some  surgeons  to  use  variously  colored  pigments  in  order  to  attempt  to  re- 
produce the  colors  of  the  iris. 

Operations  for  Conical  Cornea. — Of  the  various  procedures, 
briefly  summarized  on  page  303,  cauterization  of  the  apex  of  the 
cone  (sometimes  in  a  triangular  manner,  the  apex  of  the  triangle 
corresponding  to  the  apex  of  the  cone  [Posey])  by  means  of  galvano- 
cautery  (the  small  round  extension  point  designed  by  H.  Knapp  is 
particularly  useful)  furnish  the  best  results;  as  the  resulting  scar  may 
overlie  the  pupil  an  optical  iridectomy  may  be  required;  tattooing  the 
contraction-scar  has  been  advocated.  But  the  visual  results  are  by 
no  means  always  encouraging;  the  cauterization  may  require  repeti- 
tion; it  has  been  followed  by  glaucoma,  cataract  and  iritis.  Other 
operations  have  been  tried.  Thus  the  cauterization  may  be  preceded 
by  a  corneoscleral  trephining,  which  reducing  the  tension  prevents 
later  bulging  of  the  scar.  A.  S.  Green  and  L.  D.  Green  operate  by  a 
method  which  is  "virtually  a  combination  of  the  ElUot  and  La  CJrange 
operations."  Recently  special  operative  procedures  have  been  de- 
vised by  Meyer  Wiener  and  by  L.  Webster  Fox.  For  details  of  these 
operations  the  original  descriptions  should  be  consulted.' 

The  methods  of  reniovimj  foreign  hodic{<  embedchnl  in  tlio  cornea  and 
the  management  of  corneal  wounds  have  been  dcscribetl  (see  pages 
303,  306,  681). 

OPERATIONS  UPON  THE  IRIS 

Iridectomy.  The  following  in.stnuucnts  are  nei-essaiy :  .\  stop 
speculum,  fixation  forceps,  bent  keratome,  narrow  Graefe  knife,  iris 
forceps,  lilunt  hook,  iiis  scissors,  and  horn  or  metal  spatula.  The 
prepaiation  of  the  patient  is  described  on  ])ages  t»")4,  727,  7"JS.  The 
operation  is  performed  thus: 

The  patient  being  in  a  re(  iiiiiiieiit  jiosition  and  the  eye  being  under  the  influence 
of  cocain,  unless  the  case  is  one  of  acute  glaucoma,  where  a  general  anesthetic  is 

'  A.  fc).  and  L.  D.  Green,  Amer.  .lour  (»ith.,  .lune,  15>2();  Meyer  Wiener,  Jour. 
Amer.  Mod.  Ahhoc,  Sept.  8,  1!I17.     b.  W  .  I  n\,  Tnms.  Opth.  Soc.  of  A.  M.  .\..  1«11«). 


IRIDECTOMY 


693 


generally  preferable,  the  surgeon  separates  the  lids  by  means  of  a  speculum, 
fixates  the  eye  by  seizing  with  forceps  the  conjunctiva  and  subconjunctival  tissue 
at  a  point  directly  opposite  to  that  of  the  proposed  section,  and  introduces  the 
lance-shaped  keratome  in  the  following  manner:  The  point  of  the  knife  is  brought 
into  contact  with  the  apparent  corneoscleral  margin,  or,  in  some  instances,  about 
1  mm.  from  the  junction  of  the  sclera  with  the  cornea,  and  in  a  direction  at  right 


Fig.  324. — Ej^e  speculum. 


Fig.  325. — Fixing  forceps. 


Fig.   326. — Keratome. 


^^^^Pim*^ 


Fig.   327. — Curved  iris  forceps. 


angles  to  the  cornea,  which  direction  it  keeps  until  the  point  just  penetrates  the 
anterior  chamber.  The  handle  is  then  well  depressed,  so  that  the  point  of  the  knife 
shall  not  wound  the  iris  or  lens,  while  the  blade  is  slowly  thrust  onward,  until  the 
section  is  of  the  desired  extent  (see  Fig.  331).  The  knife  is  next  slowly  and  cau- 
tiously withdrawn,  with  its  point  well  forward  toward  the  posterior  surface  of  the 
cornea  ,  so  as  to  allow  a  slow  escape  of  the  aqueous  humor  and  to  avoid  scratching 
the  capsule  of  the  lens. 

The  first  stage  being  completed,  the  fixation  forceps  is  handed  to  an 
assistant,  who  rotates  the  globe  a  little  downward,  if  the  section  has 
been  made  upward,  and  the  surgeon  introduces  the  curved  iris  forceps, 
expanding  the  blades  so  as  to  grasp  the  pupillary  margin,  cautiously 
withdrawing  the  forceps  with  the  included  portion  of  the  iris,  and 
snipping  off  the  latter  close  to  the  wound  with  a  delicate  pair  of  curved 
scissors  (Fig.  329).  The  scissors  may  be  applied  in  the  manner 
shown  in  the  figure,  or  they  may  approach  the  withdrawn  iris  from 
below,  the  expanded  blades  being  passed  over  the  cornea  until  they 
include  the  iris  tissue,  which  is  then  excised  (see  Fig.  332). 

If  the  anterior  chamber  is  shallow,  it  is  safer  to  substitute  for 
a  keratome,  a  Graefe  cataract  knife,  making  a  puncture  and  counter- 
puncture,  and  then  cutting  in  the  same  manner  as  when  the  corneal  Fig.  328. — 
section  in  cataract  is  made.  Many  surgeons  prefer  this  method  of  Blunt  hook, 
making  the  section  in  all  iridectomies  (see  page  729). 

If  the  section  of  the  iris  should  cause  hemorrhage  into  the  anterior  chamber,  an 
attempt  may  be  made  to  remove  the  blood  by  separating  the  Ups  of  the  wound  with 
a  metal  spatula  (Fig.  330)  and  making  very  cautious  pressure  on  the  cornea,  but 
triturating  movements  carried  on  to  any  great  extent  are  done  at  the  risk  of 


694 


OPERATIONS 


bruising  the  lens  and  causing  cataract.  The  conjunctival  ouldesac  is  disinfected 
with  a  warni  physiulofiic  salt  solution,  and  the  length  of  the  wound,  and  especially 
its  angles,  are  inspected  to  see  that  the  iris  is  not  entangled.  Should  there  be 
any  entanglement  of  the  iris,  this  must  be  carefully  disengaged  with  the  spatula  or 
olive-pointed  probe  until  the  angles  of  the  wound  are  entirely 
clear  of  iris  tissue  and  the  pillars  of  the  coloboma  perfectly  in  place. 
If  the  wound  appears  clear,  the  eye  is  dressed  in  the  same  manner 
as  after  cataract  extraction  (see  page  732).  One  or  both  eyes 
may  be  bandaged,  or  covered  with  a  pad  of  aseptic  gauze  held  in 
place  with  strips  of  adhesive  plaster.  The  author  prefers  to  band- 
age both  of  them  for  the  first  forty-eight  hours.  .AJmost  always 
the  healing  is  kind,  the  anterior  chamber  is  quickly  restored,  and 
the  bandage  may  beremovedat  the  end  of  forty  eight  hours  and  the 
patient  directed  to  wear  a  shade  or  dark  glass. 

This,  in  general  terms,  describes  the  method  of  per- 
forming an  iridectomy,  which,  however,  may  require 
certain  modifications  according  to  the  indications  and 
according  to  th(>  judgment  of  the  operator. 

1.  Position  of  the  Operator. — The  operator  may  stand 
behind  the  patient's  head  and  push  the  knife  from  him  if 
he  is  making  an  upward  section,  or  he  may  stand  in  front 
of  the  patient  and  push  the  knife  toward  him  in  a  sim- 
ilarly made  section.  The  latter  procedure  has  been 
recommended  if  the  anterior  chamber  is  shallow,  as  the 
operator  can  more  readily  watch  the  point  of  the  knife. 
This  direction  refers  to  the  lance-shaped  keratome.  The 
author  prefers  to  stand  behind  the  patient's  head. 

2.  Point  of  Entrance  of  the  Keratome. — This  depends 
upon  whether  the  iridectomy  is  for  optical  purposes  or 
for  the  relief  of  increased  intra-ocular  tension.  If  for  the 
former,  its  position  should  be  exactly  at  the  apparent 
corneoscleral  border;  if  for  the  latter,  farther  back, 
about  2  mm.  from  this  position,  passing  through  the 
sclera.  Should  a  cataract  knife  be  usetl,  preferable 
always  if  the  anterior  chamber  is  shallow,  the  position  of 

Im<;.  :i2'.K — Iris  the  operator  and  the  manipulations  are  the  same  as  in 
scissors.  ^^^  extraction  of  cataract  (see  page  72')). 
3.  Position  of  the  Iridectomy. — ^If  the  iridectomy  is  for  optical  pur- 
poses, the  point  of  selection  is  governed  l)y  t  he  condition  of  the  cornea. 
The  best  i)ositioM  for  an  artificial  pui)il  is  inward  or  inward  and  ilown- 
ward,  otliei-  things  being  ('([uai.  In  optical  iridectomy  good  results  are 
obtained  and  pain  lessened  \)\  di-a\\ing  out  that  portion  of  iris  whicii  is 


~K- 


Kl(i.   AM).      .Spatula  Mini  \> 


to  be  excised  with  a  small  blunt  hooU.  In  pl.ace  of  ojtticnl  iridtctoniy, 
as  described,  Axenfeld  performs  pncoriKdl  indolDmy,  in  which  the  iris  is 
made  to  j)roiapse  through  a  small  corneal  incision  and  is  incised  with  a 


IRIDECTOMY 


695 


radial  scissor-cut,  not  excised,  and  carefully  replaced.     There  is  gradual 
separation  of  the  cut. 


Fig.  331. — Operation  of  iridectomy;  keratome  within  the  anterior  chamber. 


If  the  operation  is  to  restore  a  pupil  to  an  iris  which  has  been  bound 
down  by  extensive  synechia?,  that  portion  of  the  iris  is  excised  which  is 


Fig.  332. — Operation  of  iridectomy;  excision  of  the  piece  of  iria. 


least  attached.     Generally  it  is  best  to  perform  the  section  upward  and 
make  a  broad  iridectomy.     The  same  is  true  if  the  operation  is  per- 


696 


OPERATIONS 


formed  for  a  partial  cataract,  although  its  exact  position  must  be  gov- 
erned by  the  condition  of  the  lens. 


fJ|i  ^L^chmidl-op. 


Fig.  333. — Healed  corneal  section  after  iridectomy  (from  a  specimen  prepared  l>y  Dr. 
C.  M.  Hosmer  in  the  author's  laboratory). 


^ 


\S 


Fio.  334.      Broad  peripheral  iridectomy. 

Fio.  335. — .Small  iridectomy  with  ciliary  border  preserved. 

Vui.  336. —  Narrow  iridectomy  for  optical  purposes.      (Modified  from  Swanity.^ 

4.   The  Width  iiiui  Depth  of  the  Colohotna. — A  glance  at  Figs.  334, 
335,  and  33()  explains  three  forms  of  iiiilccfomy:  namelv,  a  i)road 


IRIDOTOMY  697 

peripheral  iridectomy,  as  in  glaucoma;  a  small  iridectomy,  with  preser- 
vation of  the  ciliary  border;  and  a  narrow  iridectomy,  for  instance,  for 
optical  purposes. 

Complications. — These  may  occur  during  the  operation  or  after  its 
completion  and  include  entrance  of  the  point  of  the  keratome  between 
the  lamellar  of  the  cornea,  due  to  beginning  the  section  with  the 
instrument  held  obliquely  and  recognized  usually  by  failure  of  any 
aqueous  humor  to  escape;  touching  the  iris  with,  or  entangling  it  upon, 
the  point  of  the  keratome  or  knife;  prolapse  of  the  iris  into  the  wound 


Fig.  337. — De  Wecker's  pince-ciseaux. 

during  the  escape  of  the  aqueous,  generally  of  no  consequence  and  if 
anything  facilitating  its  abscission;  injury  to  the  lens  either  with  the  iris 
forceps  or  because  the  point  of  the  keratome  touches  and  pricks  the 
capsule — a  serious  accident  as  cataract  is  sure  to  supervene.  Oc- 
casionally a  sudden  movement  on  the  part  of  the  patient  when  the 
iris  is  grasped  with  the  forceps  causes  an  iridodialysis  and  trouble- 
some hemorrhage.  In  iridectomies  where  the  iris  has  been  inflamed 
or  is  partly  atrophic,  the  tissue  being  very  friable,  i^  may  be  difficult 
to  seize  it  accurately,  or  it  comes  away  in  fragments;  in  these  circum- 
stances a  blunt  iris  hook  is  of  advantage.  Slow  closure  of  the  wound 
is  rare,  except  after  iridectomy  for  acute  glaucoma  where  usually 
it  is  not  disadvantageous.  Postoperative  infection  is  exceedingly 
uncommon. 

Iridotomy. — This  operation,  which  is  designed  to  manufacture  an 
artificial  pupil,  is  commonly  selected  for  eyes  from  which  the  lens  is 


Fig.  338. — Iritoectomy  (one  method) :  Fig.   339. — Iritoectomy — another   pro- 

a-b.    Cornea-iris    incision;    a-h,  b-d,  ex-  cedure  (after  Czermak). 

cision  of  iris  membranes. 

absent,  as  after  cataract  extraction,  and  in  which  the  pupil  has  become 
entirely  occluded  on  account  of  iridocyclitis.  It  may  be  performed  by 
simply  splitting  the  fibers  of  the  iris  with  a  knife-needle,  the  retraction 
usually  affording  a  sufficient  pupil;  or  a  blunt  hook  (see  Fig.  328)  may 
be  introduced  and  the  operation  converted  into  a  small  iridectomy;  or 
a  triangular-shaped  piece  of  the  iris  may  be  excised  with  delicate 
scissors  introduced  through  a  corneal  wound  {iritoectomy).  The 
method  of  de  Wecker  is  performed  as  follows : 


698 


OPERATIONS 


A  small  triangular  keratonie,  prcferal)ly  fitted  with  a  shoulder,  is  entered  into 
the  apparent  corneoscleral  margin  and  pushed  on  until  an  incision  of  about  5  mm.  is 
made.  It  is  then  slightly  withdrawn  and  again  reinserted,  this  time  causing  the 
point  to  pierce  the  iris  or  the  membrane  which  it  is  desired  to  divide.  The  instru- 
ment is  now  withdrawn,  and  the  delicate  forceps  .<:ci.ssors  of  de  ^^'ecker  is  introduced 
as  follows:  The  instrument  is  inserted  flatwise  with  closed  blades  through  the 
wound.  One  blade  is  made  to  pass  through  the  opening  in  the  iris  or  membrane 
and  the  otlier  in  front  of  it.  The  blades  are  now  puslied  onward  as  far  as  necessary, 
closed  after  the  manner  of  a  pair  of  scis.sors,  and  withdrawn.  The  cut  thus  being 
made  across  the  line  in  which  there  is  the  greatest  tension,  retraction  takes  place, 
and  if  the  operation  is  successful,  a  useful  pupil  results  isi7tiple  iridolomy) .  Instead 
of  this  procedure,  after  the  narrow  keratonie  which  has  pierced  the  cornea  and 
made  a  small  (2  mm.)  opening  in  the  iris-membrane  i.s  withdrawn,  the  iris  sci.ssors 
may  be  introduced,  as  before  described,  and  two  oblique  cuts  may  be  made  from 
either  extremity  of  the  incision  toward  the  apex  of  a  triangle,  forming  thus  a 
triangular  flap  which  is  removed  with  forceps  {iriloeclomy). 

A  more  satisfactory  operation  than  de  Wecker's  iridotomy  or 
iritoectomy  is  one  devised  by  S.  Lewis  Ziegler,  with  which  ])rocedure 
the  author  has  had  the  most  gratifyinf?  results  and  which  he  highly 
commends. 


Fkj.  .'M(». — Zienlcr's  \/-sliai)ed  iridotomy.      Knife-aoedle  cntcrod  throuuli  coiiiea. 

V-shaped  Iridotomy  {Zicgler's  Operation). — The  instruments  re- 
quired arc  a  .s})('culuiu,  ti.xatiou  forceps,  and  Ziegler's  mollified  Hays' 
knife-needle.     It  is  ijerfornuMJ  as  follows: 

First  Stage.— With  the  blade  turned  on  tlie  flat,  tlie  knife-needle  is  entered  at 
the  corneoscleral  junction,  or  tlirough  tiie  uj)per  part  of  the  cornea  (Kig.  ;Ml)l,  and 
p<issed  comjjletely  across  the  anterior  chamber  to  within  ;{  mm.  of  the  apparent  iris 
periphery.  The  knife  is  then  turned  edge  downward,  and  carried  .i  mm.  to  the  left 
of  the  vertical  plane;  (Fig.  ;j41j. 

Second  Sttiye. — The  point  is  now  allowed  to  rest  on  the  iris-Micmlinnic,  and  with 
a  dart-like  thrust  the  membrane  is  jjierced.  Then,  without  making  ])rt's.sure  on  the 
tissue  to  be  cut,  the  knife  is  drawn  gently  up  and  down  with  a  saw-like  motion, 
until  the  incision  has  been  carried  through  the  iris  ti.ssue  from  the  point  of  the 
membrane  puncture  to  just  b«'neath  the  point  of  the  corneal  i)uncture.  This 
movement  is  made  wholly  in  a  line  with  the  axis  of  the  knife,  tlie  shank  pa.ssmg 
to  and  fro  through  the  corneal  |)uncture,  and  the  loss  of  any  aipieous  being  carefully 
a\'(iiiled  in  the  Mi,'iiii|)uliit ion. 


SCLEROTOMY 


699 


Third  Stage. — The  pressure  of  the  vitreous  will  now  cause  the  edges  of  the  inci- 
sion to  immediately  bulge  open  into  a  long  oval  (Fig.  342)  through  which  the  knife- 
blade  is  raised  upward,  until  above  the  iris-membrane,  and  then  swung  across  the 
anterior  chamber  to  a  corresponding  point  on  the  right  of  the  vertical  plane,  which, 
owing  to  the  disturbance  in  the  relation  of  the  parts  made  by  the  first  cut,  is  now 
somewhat  displaced  and  the  second  puncture  must  be  made  at  least  1  mm.  farther 
over — i.  e.,  4  mm.  to  the  right  of  the  vertical  plane  (Fig.  342). 

Fourth  Stage. — With  the  knife-point  again  resting  on  the  membrane,  a  second 
puncture  is  made  by  the  same  quick  thrust,  and  the  incision  rapidly  carried  forward 
by  the  sawing  movement  to  meet  the  extremity  of  the  first  incision,  at  the  apex  of 
the  triangle,  thus  making  a  converging  V-shaped  cut  (Fig.  343).  Care  must  be 
taken  at  this  point  that  the  pressure  of  the  knife-edge  on  the  tissue  shall  be  most 
gentle,  and  that  the  second  incision  shall  terminate  a  trifle  inside  the  extremity  of 
the  first,  in  order  that  the  last  fiber  may  be  severed  and  thus  allow  the  apex  of  the 
flap  to  fall  down  behind  the  lower  part  of  the  iris-membrane.  If  the  flap  does  not 
roll  back  of  its  own  accord  it  may  be  pushed  downward  with  the  point  of  the 
knife.  When  the  operation  is  completed  the  knife  is  again  turned  on  the  flat  and 
quickly  withdrawn. ^ 


Fig.  341.— Plan  of  first 
incision. 


Fig.  342. — First  incis- 
ion completed.  Plan  of 
second  incision. 


Fig.  343.  —  Pupil  re- 
sulting from  V-shaped  ir- 
idotomy. 


Division  of  Anterior  Synechiae  {W.  Lang's  Operation) . — This  operation  is  per- 
formed with  a  pair  of  knives  closely  resembling  Knapp's  discission  knife-needle. 
The  one  is  sharp  and  the  other  blunt  pointed.  First,  the  sharp-pointed  instrument 
is  entered  through  the  corneal  tissue  at  a  point  favorably  located  for  giving  a  fair 
lateral  movement.  It  is  next  withdrawn,  and  the  blunt-pointed  knife  passed 
through  the  same  opening  across  the  anterior  chamber,  with  its  cutting  edge  in 
contact  with  the  synechiae,  which  by  means  of  a  slight  sweeping  movement  are 
divided.  Occasionally  the  iris  stretches  so  freely  that  it  is  difficult  to  sever  it. 
Practically  no  reaction  follows  the  operation,  and  the  subsequent  treatment  con- 
sists in  the  use  of  atropin  and  a  compress  bandage.  If  it  has  been  successful,  the 
iris  may  be  dilated  and  the  distorted  pupil  become  round. 

This  operation,  according  to  Lang,  is  suited  to  adhesion  of  the  iris  or  capsule  to 
the  wound  after  cataract  extraction,  to  traumatic  prolapses  where  a  broad  width  of 
iris  is  clamped  in  the  scar,  to  small  adhesions  due  to  perforating  wounds  or  ulcers, 
and,  finally,  to  large  adherent  leukomas.  It  is  a  useful  operation,  but  in  the 
last  group  the  effects  are  the  least  satisfactory. 


OPERATIONS  UPON  THE  SCLERA 

Sclerotomy  {Anterior  Sderotomij) . — This  is  an  operation  first  per- 
formed by  Quaglino,  and  improved  and  advocated  by  de  Wecker,  which 
is  practised  for  the  relief  of  glaucoma,  and  in  the  hands  of  some  surgeons 
is  made  to  substitute  the  operation  of  iridectomy  (see  page  692).  It  is 
especially  recommended  in  chronic  glaucoma  with  deep  anterior  cham- 
ber, in  inflammatory  glaucoma  with  atrophy  of  the  iris,  and  where 
iridectomy  fails  to  reduce  tension  or  to  relieve  the  pain  of  old,  blind 
glaucomatous  eyes.     It  is  performed  as  follows: 

^  The  description  of  this  operation  is  in  Dr.  Ziegler's  own  words,  and  the  figures 
which  illustrate  it  are  his,  and  have  been  kindly  loaned  for  reproduction. 


700 


OPERATIONS 


Fig.  344. — Lines  of  incision  in 
sclerotomy. 


A  narrow  Graefe's  cataract  knife,  or  a  specially  constructed  knife  known  as  a 
sclerotome,  \s  passed  through  the  sclera,  1  mm.  from  the  margin  of  the  clear  cornea 
in  front  of  the  iris,  and  brought  out  at  a  corresponding  point  on  the  other  side — i.  e., 
the  puncture  and  counterpuncture  are  placed  as  if  the  surgeon  intended  to  form  a 
flap  2  to  2.5  mm.  in  lieight  out  of  the  upper  (or  lower)  part  of  the  cornea.  The 
puncture  and  counterpuncture  are  enlarged  with  a  slight  sawing  movement  of  the 
knife,  which  i.s  slowly  withdrawn  before  the  section  is  complete,  leaving  the  central 

quarter  of  the  sclerotic  flap,  and  as  much  of  the 
conjunctiva  as  possible,  except  where  punctured, 
undivided.  Thus,  at  the  upper  (or  lower)  margin 
of  the  cornea  there  remains  a  bridge  formed  of 
.sclera  which  connects  the  parts  below  it.  If  pro- 
lapse of  the  iris  occurs,  replacement  should  be 
attempted  with  a  horn  spatula.  In  the  event  of 
failure  the  prolapsed  iris  must  be  excised  and  the 
sclerotomj^  converted  into  an  iridectomy.  Pre- 
ceding the  operation,  eserin  should  be  used  to  contract  the  pupil,  and  this  drug 
must  be  continued  during  the  process  of  healing. 

Posterior  Sclerotomy. — This  is  performed  by  entering  a  Graefe  cataract  knife 
at  a  point  between  the  external  and  inferior  recti  muscles,  8  mm.  from  the  corneal 
margin,  and  passing  the  blade  through  the  sclera  toward  the  center  of  the  eyeball  to 
a  depth  of  4  to  6  mm.  As  the  knife  is  slowly  withdrawn  it  is  made  to  execute  a 
quarter  turn,  the  effect  being  the  formation  of  a  slight  triangular  wound,  which 
favors  filtration.  The  operation  is  employed  in  hemorrhagic  glaucoma,  preUmin- 
ary  to  iridectomy  (see  page  420),  especially  when  the  anterior  chamber  is  very 
shallow,  and  in  retinal  detachment  (see  page  494). 

Internal  sclerotovnj  was  practised  by  de  Wecker  and  by  de  Vincentiis  under  the 
name  of  incision  of  the  tissue  of  the  angle  of  the  iris.  The  incision  is  similar  to 
anterior  sclerotomy,  with  omission  of  the  counterpuncture,  in  place  of  which  the 
arches  of  the  pectinate  ligament  are  incised. 

Combined  Iridectomy  and  Sclerectomy  {Lagrange  s  Operation). 
The  operation,  according  to  Lagrange,  is  performed  as  follows: 


Viu.  .'^45. — Lagrungo'a  oj<i.-i;i(ion;  Section  of  tlie  acloiji  :ind  conjunctiva. 

With  a  CJraefe  knife  the  sclera  is  punctured  at  the  outer  side  1  mm.  from  the 
linibus  and  the  counferj)uncture  is  made  at  a  corri'spoiidiiig  point.  The  .sclera  is 
divided  in  the  iridoforneal  angle  and  tiie  .section  iuchule.s  tiie  upper  fourth  of  the 
cornea.  In  terminating  the  inei.sion  tiie  cutting  edge  of  the  blade  is  directe<l  back- 
ward in  such  a  way  as  to  l)evel  the  sclera,  and  wlieu  tiie  knife  is  beneatii  tlie  con- 
junctiva a  conjunctival  flaj)  (ai)out  4  mm.  in  iieigiit )  is  made.  In  the  second 
Btage  of  tlie  o|)eration  the  conjunctival  ilaj)  is  rai.sed,  but  not  cut  in  any  way,  and 
di.iwn  l)ack  on  tlie  cornea.  'J'his  maneuver  tilts  the  edge  or  tongue  of  the  scleral 
(lap  upward.  Tliis  is  next  removed  with  a  Hliarj)  curved  pair  of  .scissors,  and  a 
sullicieiitly  "large  piece  of  the  sclera  is  resected  from  the  exterior  lip  of  the  incision. 


COMBINED    IRIDECTOMY    AND    SCLERECTOMY 


701 


FiBally,  iridectomy  is  performed  in  the  usual  way,  and  the  flap  of  conjunctiva  de- 
tached in  the  first  stage  of  the  operation  is  replaced,  thus  covering  the  defect  in  the 
sclera.  The  steps  of  the  operation  are  evident  by  an  examination  of  Figs.  345  to 
347  borrowed  from  Lagrange's  original  paper.  It  is  not  necessary  to  make  a 
very  large  flap,  4  to  5  mm.  is  sufficient.     Weeks,  as  the  result  of  a  large  experience 


Fig.  346. — Lagrange's  operation:  Resection  of  the  sclera. 

with  this  operation,  recommends  that  it  shall  be  performed  as  described  by  La- 
grange, except  that  the  incision  shall  be  not  more  than  5  mm.  (Lagrange  advised 
7  mm.).  The  shorter  incision  obviates  the  danger  of  prolapse  of  the  ciliary  body 
or  of  the  lens  into  the  wound  and  lessens  the  chance  of  escape  of  vitreous.  The 
after  treatment  should  include,  beginning  fortj'-eight  hours  after  the  operation, 
massage  of  the  eyeball,  which  may  continued  for  some  daj^s  or  even  weeks  accord- 
ing to  the  conditions  CVVeeks). 


Fig.   347. — Lagrange's  operation:   Making  the  iridectomy. 

By  means  of  this  sclerecto-iridectomy  a  communication  is  made 
between  chambers  of  the  eye  and  the  perichoroidal  space  and  the  sub- 
conjunctival cellular  tissue.  The  hypertension  of  the  glaucomatous 
eye,  Lagrange  maintains,  is  permanently  relieved  bj'  the  estabhshment 
of  a  fistulous  track  between  the  anterior  chamber  and  the  subcon- 
junctival tissue.  Iridectomy,  he  is  wiUing  to  admit,  cures  acute 
glaucoma,  but  not  the  chronic  variety.  Simple  sclerectomy,  as  prac- 
tised by  Lagrange,  is  performed  in  precisely  the  same  way;  that  is,  the 
first  two  steps  of  the  operation  are  taken,  iridectomy  being  omitted. 


702  OPERATIONS 

Herbert  has  devised  an  operation  which,  he  is  satisfied,  produces  a 
permeable  scar. 

Wedge-isolation  Operation  (Herbert's  Operation).  — It  is  thus  described  by 
Rallantync:  With  a  narrow  Graefe  knife  the  operator  proceeds  as  if  his  intention 
was  to  form  a  shallow  corneoscleral  flap.  Puncture  and  counterpuncture  are  made 
close  to  the  margin  of  the  cornea,  the  knife-point  having  previously  passed  through 
the  conjunctiva  a  little  distance  above  the  point  of  entrance.  The  upward  cut  is 
made  with  the  knife  blade  bevelled  a  trifle  backward  and  a  bridge  of  .sclera  is  left 
undivided.  The  knife  is  ne.vt  brought  down  and  its  edge  turned  forward  and  a 
forward  cut  is  made  perpendicular  to  the  scleral  .surface,  care  being  taken  not  to  cut 
theconjunctiva.  This  incision  forms  the  lowerboundary  ofthewedge.  Theknife 
is  now  drawn  backward  and  rotated  upward  so  that  it  lies  in  the  original  incision, 
which  is  continued  upward  until  the  blade  emerges  through  the  sclera  1  mm.  from 
the  corneal  margin.  This  completes  the  isolation  of  the  wedge.  A  long  conjuncti- 
val flap  is  ne.\t  formed,  left  attached  at  its  upper  extremity,  bj'  turning  the  knife 
upward  and  backward.  A  small,  ba.sal  iridectomy  is  made  to  prevent  iris  prolapse. 
This  technic  has  been  modified  in  various  ways:  thus,  the  primary  incision  ma}'  be 
made  with  a  bent  keratome  and  the  lateral  cuts  with  a  short  narrow  knife.  N. 
Bishop  Harman  has  devised  "twin  scissors"  for  the  purpose  of  forming  the  lateral 
incisions. 

Sclerectomy  with  Punch  Forceps  (Holth's  Operation). — With  a  Graefe  knife 
puncture  and  counterpuncture  are  made  in  the  sclera  8  mm.  from  each  other  and 
1  mm.  from  the  limbus.  Next,  a  scleral  flap  2.5  mm.  high  and  a  conjunctival  flap 
extending  to  8  mm.  from  the  limbus  are  formed.  The  conjunctiva  is  now  freed 
from  the  anterior  lip  of  the  scleral  flap,  raised  with  forceps,  and  a  piece  of  the  scleral 
flap.  3  by  1.5  mm.,  is  removed  by  means  of  the  punch  forceps  (Holth-Vaclier's,  de 
Lapersonne's,  or  Ziegler's  instrument  may  be  used).  A  basal  or  complete  iridec- 
tomy may  be  performed,  after  which  the  conjunctiva  is  replaced.  The  primary 
incision  may  be  made  with  a  keratome  which  pierces  the  conjunctiva  10  mm.  above 
the  cornea,  enters  the  sclera  2.5  mm.  from  the  limbus,  and  penetrates  obliquely  into 
the  anterior  chamber. 

The  important  manner  in  which  the  results  of  these  operations  differ 
from  cystoid  cicatrices  (see  page  422)  is  that  the  scar  is  free  from  adhe- 
sion to  the  uveal  tract.  Some  difference  of  opinion  exists  in  regard  to 
their  permanent  value,  and  Henderson,  although  willing  to  admit  that 
at  an  early  stage  such  a  scar  as  has  been  described  may  be  permeable 
and  that  filtration  may  take  place,  believes  it  soon  becomes  imper- 
meable, owing  to  the  ingrowth  of  epithelium,  and,  tiierefore.  unless  a 
fistula  is  made,  filtration  ceases.  Lagrange  believes  that  in  his  ()i)eratit)n 
the  fistulous  track,  Ix'fore  mentioned,  is  fornieil.  The  author  has  not 
had  experience  with  Herbert's  operation,  but  has  i)erformed  the  La-  | 

grange  operation  with  satisfaction  in  cases  of  chronic  (simjile)  glaucoma. 
He  has  not  employed  it  in  cases  of  acute  glaucoma,  in  which  form  of  tlH> 
disease  a  well-placed  i)eripheral  iridectomy  has  usually  yielded  excel- 
lent results.  Weeks  recommends  the  operation,  except  in  luij)htlKil- 
mos,  some  types  of  glaucoma  with  dec])  anterior  chamber  atid  cases  m] 

of  chronic  glaucoma  with  relati\cl\-  low  hypertension.     .Vccording  to  * 

Meller,  the  delay  in  re-formation  of  the  anterior  chamber,  which  is 
noticeable  in  some  eyes  after  Lagrange's  ojx'ration,  is  (hie  to  detach- 
ment ui  the  choroid.  He  regards  the  o])eralion  ;is  unsatisfactory  if  the 
intra-ocular  tension  is  very  high.  He  reports  1  ..i  ])er  cent,  of  late 
infections  in  .'iSO  La'j;range  ojierations.      Inlr.a-ocular  htiiionhagc,  iritis, 


SCLEROCORNEAL  TREPHINING 


703 


prolapse  of  the  ciliary  body  and  loss  of  vitreous  have  been  noted  as 
complications. 

Sclerectomy  with  a  Trephine. — Trephining  the  sclera  for  the 
purpose  of  relieving  the  increased  intra-ocular  tension  of  glaucoma  is 
not  a  new  procedure.  Long  ago  it  was  proposed  by  Argyll  Robertson, 
Strawbridge,  Blanco,  and  Froelich,  but  their  operations  differed  in 
many  respects  from  the  newer  procedures  of  sclei'al  trephining  which 
have  been  suggested,  particularly  by  Fergus  and  by  Elliot. 

Scleral  Trephining  (Fergus'  Operation). — The  technic  is  thus  summarized  by 
Ballantyne:  A  conjunctival  flap  is  dissected  up  toward  the  cornea  and  laid  over  the 
corneal  surface,  while  with  a  Bowman's  trephine  a  small  disk  of  sclera  is  removed 
1  or  2  mm.  from  the  apparent  corneal  margin.  Next,  an  iris  repositor  is  passed 
from  the  trephine  opening  into  the  anterior  chamber,  keeping  it  in  close  contact 
with  the  sclera  and  cornea.  The  conjunctiva  is  then  replaced  and  stitched  into 
position. 

Sclerocorneal  Trephining  (ElUofs  Operation). — The  description 


Fig.  348. — Sclerocorneal    trephining:    conjunctival    flap    reflected;    trephine     opening 
partly  in  the  cornea  and  partly  in  the  sclera.     (After  S.  Lewis  Ziegler .) 

of  the  technic  of  this  operation  which  has  achieved  a  world-wide 
reputation,  at  the  author's  reque.st,  has  been  written  by  Lieut. -Colonel 
Elliot. 

1.  The  Quadrant  of  the  Eye  Selected. — This  should  invariably  be  the  upper 
unless  there  is  some  strong  contra-indication.  The  presence  of  an  upward  colo- 
boma  resulting  from  a  previous  iridectomy  does  not  contra-indicate  an  upward 
trephining;  on  the  contrary,  the  operation  is  made  easier  thereby. 

2.  The  Flap. — This  should  be  large.  The  incision  runs  roughly  concentric  with 
the  limbus  and  ends  on  either  side  opposite  the  highest  point  of  the  cornea,  and 
about  8  mm.  from  its  inner  and  outer  sides.     The  conjunctiva  should  be  seized  as 


704 


OPERATIONS 


liigh  as  possible  with  forceps  and  drawn  well  down,  while  the  patient  looks  stronglv 
toward  his  feet.  One  free  horizontal  cut,  followed  by  a  couple  of  snips  at  each  side, 
will  outline  the  flap.  Only  the  central  area  of  the  flap  thus  marked  is  to  be  dis- 
sected up.  As  we  approach  the  limbus,  we  should  work  down  to  the  sclera  and 
.should  lay  the  latter  bare  in  the  last  few  millimeters  of  the  wound.  We  must  then 
clearly  define  the  linii)u.s  as  a  rounded  ridge  overhanging  the  adjacent  sclera.  The 
area  for  the  application  of  the  trephine  must  be  cleared  of  all  tags  of  loose  tissue. 
The  conjunctival  flap  should  be  gently  drawn  downward  by  the  aid  of  a  blunt  in- 
strument, and  the  cornea  is  then  to  be  split  with  the  scissor  points  or  with  any  other 
fairly  sharp  instrument.  .\s  the  dissection  proceeds  the  "dark  crescent"  of  the 
cornea  can  be  seen  as  an  area  convex  in  outline  toward  the  sclera,  and  with  a 
straight  edge  on  the  corneal  side.  It  is  sufficient  to  spht  the  cornea  over  an  area 
1  mm.  in  depth.  This  enables  a  2-mm.  trephine  to  be  appUed  half  on  the  cornea 
and  half  on  the  sclera. 

3.  The  Application  of  the  Trephine. — The  trephine  (2  mm.  in  diameter)  should 
be  placed  as  far  forward  as  possible,  being  slid  into  place  from  the  scleral  side,  the 
edge  of  the  flap  being  meantime  keenly  watched,  so  as  to  avoid  buttonholing.  A 
sharp  blade  is  required  to  make  sure  of  cutting  a  definite  groove  in  the  corneosclera 


.j^rt^'^'^'\IWJlfl/l/,j 


Fig.  .349. — sp,  Speculum;  i,  i,  incision;  c,  cornea;  t,  trephine  hole;  p,  pupil;  a.  a,  chan- 
nels in  conjunctiva  along  which  filtration  fluid  passes  to  enter  the  main  area  of  the  8ul>- 
conjunctival  space.     (Elliot.) 


on  its  fir.st  application.  Our  object  should  be  to  make  the  blade  cut  through  first 
on  its  corneal  edge,  and  to  ensure  this  we  must  slope  the  upper  edge  of  the  instru- 
ment a  little  toward  the  patient's  feet,  so  that  the  disk  cut  out  may  be  hinged  on  its 
scleral  side.  A  bead  of  iris  tissue  will  prolapse  through  the  corneal  siile  of  the  hole, 
pushing  the  disk  before  it.  The  disk  together  with  the  prolapsed  iris  is  seized  in  a 
pair  of  iris  forceps  and  the  two  structures  are  cut  with  one  snip  of  the  scissors,  thus 
I)erforming  a  sclerecto-iridectomy  with  a  single  cut.  The  amount  of  disk  removed 
can  be  graduated  according  to  the  needs  of  the  case. 

4.  Toilet  of  Wound. — The  iris  is  replaced  by  massage,  aided  by  an  irrigator,  if 
necessary,  and  a  dressing  is  applied.  The  r61e  of  the  iridectomj*  is  the  same  here 
as  it  is  in  cataract  extraction;  no  more,  no  less.  It  is  safer,  in  European  practice,  to 
secure  tlic  flap  by  means  of  one  or  two  sutuTes. 

5.  Instillation  of  Drops. — From  the  second  or  third  day  onward,  provided  tlie 
tension  i.s  down,  atropin  (Ir(jj)s  are  freely  instilled. 

6.  After-treatment. —  The  unoperated  eye  is  openeil  after  twenty-four  hours, 
and  both  eyes  after  fortj-eigiit  hours.  The  patient  sits  up  in  bed  on  the  second  day 
and  moves  about  the  room  on  the  third  (I;iy. 

N.'iturally,    vurious  opcralor.s  have  adviscnl   inodificatioiis  of  the 
procedure;  for  example,  Iv.  Webster  l*\)x  (who  prefers  his  type  of  tlie 


SCLEROCORNEAL    TREPHINING 


705 


von  Hippel  trephine)  forms  the  conjunctival  flap  as  in  the  Van  Lint 
sliding  flap  in  cataract  extraction,  and  McReynolds  dissects  out  a  piece 
of  sclerocornea  with  a  knife-point  after  fixing  it  with  a  traction  suture. 
In  the  opinion  of  the  author  the  most  satisfactory  results  are  obtained 
if  Elliot's  method  is  exactly  followed.  The  author  prefers  a  hand- 
driven  trephine;  good  models  are  those  recommended  by  Stephenson, 
Lang,  and  Elliot. 

Indications. — Although  many  surgeons  utilize  this  operation  in 
acute  glaucoma,  the  author  is  unconvinced  that  it  is  a  better  procedure 
than  a  technically  correct  iridectomy.  It  and  other  methods  which 
secure  a  so-called  ''filtering  area"  are  better  operations  in  chronic, 
non-congestive  glaucoma  than  iridectomy.  If  an  iridectomy  in  this 
disease  has  failed  of  its  purpose,  corneoscleral  trephining  is  preferable 
to  a  second  iridectomy  or  sclerotomy.  In  chronic  glaucoma  with 
greatly  contracted  field  it  is  a  safer  operation  than  ordinary  iridec- 
tomy. It  is  not  a  wise  pi'ocedure  if  glaucoma  is  complicated  with 
cataract,  but  it  should  be  considered  in  glaucoma  secondary  to  cataract 
in  those  eyes  in  which  the  vitreous  and  aqueous  chambers  are  not  in 
communication.  It  may  be  performed  in  absolute  glaucoma  in  the 
hope  of  preventing  enucleation,  but  this  prevention  is  not  assured. 
It  is  not  likely  to  meet  with  success  in  glaucoma  due  to  intra-ocular 
hemorrhage  and  thrombosis  of  the  central  retinal  veins;  it  may  be  tried 
in  staphyloma  and  secondary  glaucoma,  but  the  outlook  is  not  a  bril- 
liant one.  In  buphthalmos  it  has  achieved  satisfactory  resulits 
(see  also  page  426). 

Complications  and  Causes  of 
Failure. — The  chief  complica- 
tions are  buttonholing  the 
conjunctival  flap,  extensive  hem- 
orrhage into  the  anterior  cham- 
ber, entrance  of  the  scleral 
button  into  the  aqueous 
chamber,  wounding  the  lens, 
loss  of  vitreous  (which  should 
never  occur  if  the  trephine 
opening  is  correctly  placed);  intra-ocular  hemorrhage,  detachment 
of  the  choroid,  purulent  infection,  and  iritis.  After  this  operation 
iritis  occurs  not  infrequently,  and  appears  early  either  as  a  quiet  iritis, 
with  almost  no  signs  of  inflammation  of  the  uveal  tract,  but  with  the 
gradual  development  of  soft  synechise,  or  arises  as  a  sharp,  plastic 
inflammation  at  a  later  period  than  the  first  type  of  the  affection. 
Parker's  investigations  indicate  that  iritis  is  much  less  apt  to  develop  if 
complete  iridectoni}'^  is  part  of  the  operative  procedure — a  significant 
observation.  Its  incidence  should  be  prevented  by  the  early  use  of  a 
mydriatic — the  author  prefers  scopolamin.  Occasionally,  the  an- 
terior chamber  is  reestablished  slowly  and  a  week  or  more  may 
elapse  before  it  is  reformed.  This  may  be  due  to  detachment  of 
the  choroid  which  almost  always  subsides,  or  to  failure  in  even  heal- 


FiG.   350. 


-Stephenson's  sclerectomy 
trephines. 


706  OPERATIONS 

ing  of  the  conjunctival  incision.  In  the  latter  circumstancps  the  line 
of  incision  should  be  touched  with  a  2  per  cent  solution  of  nitrate 
of  silver. 

The  causes  of  failure  in  this  operation,  according  to  Elliot,  depend 
upon  forward  dislocation  of  the  lens  or  vitreous  body  and  prolapse  of 
uveal  tissue  into  the  trephine  hole,  which  is  blocked  by  proliferated  con- 
nective tissue  either  from  the  eipsclera  or  the  uvea.  In  Stephenson's 
observations  the  trephine  tract  was  occluded  by  vascular  fibronuclear 
tissue  and  iris  pigment.  A  number  of  late  infections  (from  a  few  weeks 
to  some  months  after  operation)  are  now  on  record,  the  process  varying 
in  severity  from  an  infected  iridocyclitis  and  hypopyon  to  panoph- 
thalmitis. This  disaster  is  chiefly  to  be  feared  if  the  conjunctival  flap 
is  too  thin;  it  should  be  formed  of  a  proper  thickness.  Late  infections 
not  pecuhar,  however,  to  this  operation  (see  page  702)  are  due  to  the 
entrance  of  micro-organisms  through  delicate  and  invisible  fistulas  in 
the  conjunctiva  covering  the  trephine  opening.  After  this  operation 
patients  with  very  thinly  covered  "filtering  areas"  should  be  carefully 
watched  and  should  daily  use  a  collyrium  of  boric  acid  and  sulphate  of 
zinc  (Gifford).  Fluorescein  should  be  employed  to  detect  the  presence 
of  epithelial  defects  (Axenfeld,  Harms).  Pronounced  hypotomy,  as 
it  may  occur  after  this  operation,  A.  Knapp  regards  as  a  dangerous 
complication  and  he  advises  a  small  trephine  and  removal  of  a  small 
disk. 

Iridotasis  (Borthen's  Operation). — This  operation,  devised  bj^ 
Borthen,  has  many  advocates  and  in  this  country  is  especiall}'  com- 
mended by  David  Harrower.  The  method  of  operating,  according 
to  this  surgeon,  who  essentially  follows  Borthen's  technic,  is  as  follows: 

Fifteen  minutes  prior  to  operation  a  drop  of  a  1  per  cent,  solution  of  atropin 
is  instilled.  Cocain  anesthesia  follows.  Next,  the  conjunctiva  being  grasped  with 
forceps  10  mm.  back  from  the  cornea,  an  incision,  10  to  12  mm.  in  length 
parallel  with  the  corneal  line,  is  made  in  this  membrane  which  is  then  separated 
from  the  sclera  to  the  corneoscleral  junction.  Finally,  an  incision,  4  mm.  wide,  is 
made  just  behind  the  corneal  margin,  through  which  a  forceps  is  introduced, 
the  iris  grasped  at  its  pupillary  margin,  withdrawn  into  the  .scleral  opening  and 
the  conjunctiva  smoothlj'  replaced  over  it.  If  successful  a  satisfactory  "filtration 
bleb"  results. 

CompliitatioMS  are  uncommon  and  healing  is  usually  ])rompt,  but 
one  late  infection  has  been  recorded  (Dunbar  Kdv)  and  n^turn  of  hjgh 
tension  has  been  reported  (A.  Knapp).  The  operation  is  advised  in 
chronic  glaucoma  but  it  has  also  l)een  utilized  in  acute  glaucoma.  In 
Holth's  iridoclcinis  the  inci.sed  iris  is  incarcerated  in  the  scleral  kera- 
tome  incision  and  the  conjunctival  fla))  allowed  to  heal  over  it. 

Zorah's  oycialion  consists  essentially  of  thread  drainage  of  the  ante- 
rior chamber.  A  silk  thread  is  introduced  into  the  aqueous  chamber 
and  covered  with  a  conjunctiv.-d  flap.  ( ";ise\-  \\'ood,  in  this  country, 
has  ))rac(ised  tliis  ])rocedure. 

Vj.  .1.  Curran,  believing  lli.il  the  How  of  aciueous  from  liie 
posterior  to  llie  ;iiileiMor    cliainlter    is    iiiipeiled   in  gl;iucoMia   "on  ac- 


CYCLODIALYSIS 


707 


count  of  the  iris  hugging  the  lens  over  too  great  a  surface,"  has 
designed  an  operation  the  purpose  of  which  is  to  establish  a  drain 
from  the  posterior  to  the  anterior  chamber.  It  consists  essentially 
in  cutting  with  a  delicate  knife-needle  a  1  mm.  hole  in  the  upper 
surface  of  the  iris. 

Cyclodialysis  (Heine's  Operation). — By  means  of  this  operation, 
suggested  by  Heine  in  1905,  an  endeavor  is  made  to  form  an  artificial 
communication  between  the  anterior  chamber  and  the  suprachoroidal 
space,  but  there  is  no  positive  proof  that  after  it  drainage  occurs  into 
this  space,  although  it  is  possible  that  a  successful  cyclodialysis  reopens 
the  9,ngle  and  brings  it  again  into  communication  with  Schlemm's 
canal.     It  is  performed  as  follows: 

After  the  reflection  of  a  small 
conjunctival  flap,  preferably  on  the 
outer  side  of  the  eyeball,  an  open- 
ing is  made  into  the  sclera  with  a 
straight  lance,  parallel  to  the  cor- 
neal margin  and  from  6  to  8  mm. 
away  from  it,  without  injuring  the 
uveal  tissue.  This  opening  should 
be  from  2  to  3  mm.  in  length,  and 
through  it  a  spatula  is  introduced 
with  which  the  ciliary  body  is  sepa- 
rated from  the  overlying  sclera  and  - 
the  instrument  gradually  pushed 
through  the  ligamentum  pectina- 
tum  into  the  anterior  chamber. 
Finally,  a  quadrant  of  the  iris 
periphery  is  detached.  Occasion- 
ally some  difficulty  is  experienced 
in  passing  the  spatula  between  the 
ciliary  body  and  the  sclera  into  the 
anterior  chamber,  and  in  a  few  in-  jr^^     351.— Corneoscleral   trephining;    note 

stances  hemorrhage  into  this  cham-  the  filtering  area  at  corneoscleral  margin;  small 
ber  has  occurred.  peripheral  iridectomy. 


^"^^^'^^moi^m^} 


According  to  Meller,  in  successful  cases  reduction  of  tension  is  not 
noticeable  until  the  following  day.  All  increased  tension  should  disap- 
pear by  the  second  or,  at  the  latest,  by  the  third  day.  Occasionally 
subnormal  tension  results.  If  the  tension  remains  low  for  a  week,  the 
ultimate  result  is  likely  to  be  favorable.  The  operation  has  proved  to 
be  satisfactory  in  secondary  glaucoma  due  to  anterior  synechia  or  sub- 
luxation of  the  lens,  in  glaucoma  following  cataract  extraction,  in 
return  of  tension  following  a  Lagrange  or  Elliot  operation  in  cases  of 
chronic  glaucoma  where  iridectomy  has  failed,  and  in  absolute  glau- 
coma. It  is  contraindicated  in  acute  glaucoma  and  in  glaucoma  of 
an  exudative  type  (H.  S.  Gradle).  The  author  has  frequently  per- 
formed this  operation  and  some  of  the  results  have  been  perma- 
nently good.  It  may  be  repeated  several  times  if  the  high  tension 
returns.  It  is  not  an  operation  which  can  replace  iridectomy  or  other 
well  established  procedures. 


708  OPERATIONS 

Operations  for  Detachment  of  the  Retina. — Some  of  the 
means  devised  for  the  cure  of  retinal  detachment  from  the  operative 
standpoint   have   been  referred  to  on   page  494.     Three   additional  _ 

procedures  are  the  following:  ■ 

1.  Trephining  the  Sclera  for  Detachment  of  the  Retina. — Attention 
to  this  o])('rati()n  in  this  rcfrard  was  first  ))r(iiiiinciitl\' called  bv  Walter 
R.Parker. 

His  tcchnic  consists  essentially,  after  raising  a  suitable  flap  of  conjunctiva,  in 
making  a  2  mm.  trephine  opening  in  the  sclera  at  a  point  corresponding  to  the 
lowest  portion  of  the  detached  retina.  I'sually,  there  is  a  free  escape  of  subretinal 
fluid,  followed  sometimes  by  an  escape  of  a  few  drops  of  vitreous.  The  conjunc- 
tival flap  being  replaced  and  secured  by  a  single  suture,  the  patient  is  required 
to  rest  in  bed  for  ten  days  in  such  a  position  as  to  favor  replacement  of  the  retina. 

Edgar  Thomson  and  T.  H.  Curtin.  using  a  2  or  3  mm.  trephine  and  selecting 
for  the  site  of  operation  the  most  dependent  position  which  is  possible  within  the 
area  of  detachir.ent,  after  the  escape  of  the  suprachoroidal  fluid  and  replacement 
of  the  conjunctival  flap  keep  the  patient  in  bed  (pupil  dilated  and  bandage 
applied)  for  ten  day.s.  At  the  expiration  of  this  period  the  needle  of  a  small  aspir- 
ating sj'ringe  is  inserted  into  the  subretinal  space  through  the  conjunctiva  and 
choroid  and  the  fluid  forcibly  aspirated.  This  aspiration  may  be  repeated,  if 
necessary-  and  may  be  performed  immediately  on  completion  of  the  trephining. 

2.  Sclerotomy  Combined  with  Electrolytic  Punctures  (Verhoeff's 
method). 

Verhoeff  first  performs  posterior  sclerotomy  in  the  usual  manner,  and  keeps 
the  patient  in  bed  with  both  eyes  bandaged  for  a  week.  At  the  conclusion  of  this 
preparatory  treatment,  the  object  of  which  is  to  bring  the  retina  in  contact  with 
the  choroid,  he  makes  a  large  number  of  minute  punctures  through  the  sclera  and 
retina  by  electrolysis,  employing  a  small  steel,  half  curved  eye  needle,  the  current 
being  obtained  from  a  series  of  six  drj-  batteries  of  Ifo  volts  each,  the  positive 
electrode  being  applied  by  means  of  a  wet  sponge  to  the  cheek.  The  needle  point 
is  pressed  firmly  against  the  globe  until  it  penetrates  the  ball,  when  it  is  pulled 
back  slightly,  so  that  the  point  protrudes  only  a  millimeter  or  two  through  the 
vitreous,  where  it  is  allowed  to  remain  for  about  five  seconds.  The  number  of 
punctures  must  vary  according  to  the  extent  of  the  detachment. 

3.  Resection  of  the  Sclera  (MuUcr's  method). — This  operation, 
devised  by  Mlillcr,  is  advocated  by  Torok  who  describes  it  as  follows: 

The  external  rectus  is  exposed,  two  sutures  inserted,  and  the  nmscle  severed 
between  them.  An  elliptical  .space,  20  mm.  in  length  and  10  mm.  in  width,  is 
outlined  on  the  sclera,  its  anterior  end  behind  the  insertion  of  the  muscle  ami  its 
posterior  border  toward  the  eciuator.  Tiie  elliptical  incision  is  next  made  half  way 
through  the  sclera  and  five  fine  catgut  sutures  are  inserted  from  within  or  within 
outward.  The  sutures  being  rai.sed  out  of  the  way  the  posterior  border  of  the 
incision  is  carried  through  the  entire  thickness  of  the  sclera,  the  choroid  sei)arntcd 
from  the  sclera,  the  sutures  diawn  together  whereby  the  scleral  flaj)  is  pushed  into 
the  pocket  between  the  sclera  and  the  choioid:  i)rior  to  tying  the  last  suture  the 
choroid  is  punctured.  The  divided  muscle  is  sutureil  in  j)lace,  the  conjunctival 
wound  closed,  atropin  is  instilled  and  the  j)atieiit  recjuired  to  remain  in  be^J  in  a 
prone  position  for  eight  days. 

Successes  have  been  reported  with  all  of  these  operations  in  the 
sense  that  vision  was  irnj)rovcd  and  the  field  widciu-d  or  n\stored, 
soinctinics  only  l('ini)or;iril>'  and  sometimes  lon^i  enduring.      In  some 


ENUCLEATION  OF  THE  EYEBALL  709 

instances  the  operations  have  been  failures  and  in  others  conditions 
have  been  worse  after  their  performance.  The  author  has  had  no  ex- 
perience with  Verhoeff's  method  nor  with  Miiller's  resection.  His  best 
results  have  been  secured  with  posterior  sclerotomy,  followed  by  sub- 
conjunctival injections  of  phj^siologic  salt  solution  or  sodium  citrate 
(4  to  5  per  cent.),  rest  in  bed  and  locally  dionin  and  atropin;  as 
adjuncts  diaphoresis  and  diuresis  have  also  been  employed.  On  the 
whole,  with  a  few  exceptions,  the  permanent  results  have  been  disap- 
pointing. Certainly,  in  general  terms,  the  history  of  the  results  of 
operations  in  detachment  of  the  retina  is  not  a  brilliant  chapter. 

OPERATIONS  ON  THE  GLOBE  AND  REMOVAL  OF  FOREIG  N  BODIES 

Enucleation  of  the  Eyeball. — The  following  instruments  are 
necessary:  A  stop  speculum,  j&xation  forceps,  dissecting  forceps, 
strabismus  hook,  and  a  pair  of  scissors  curved  on  the  fiat  (enucleation 
scissors) . 

The  lids  are  held  apart  with  a  stop  speculum  whUe  the  surgeon  divides  the  con- 
junctiva and  adjacent  fascia  with  scissors  in  a  circle  as  close  as  possible  to  the 
margin  of  the  cornea.  This  is  sometimes  called  "circumcising  the  cornea."  The 
tendons  of  the  ocular  muscles,  beginning  mth  the  superior  rectus,  are  next  succes- 
sivelj'  raised  upon  a  strabismus  hook  and  divided.  The  eye  being  made  to  start 
forward  by  inserting  the  stop  speculum  somewhat  more  deeply,  the  e3'e  is  drawn 
forward,  the  face  of  the  patient  being  turned  toward  the  operator,  and  the  curved 
scissors  are  introduced  on  the  nasal  side  between  the  severed  conjunctiva  and  the 
freed  eyeball,  and  made  to  follow  the  curve  of  the  latter  until  the  optic  nerve  is 
reached,  where  the  blades  are  expanded  and  the  nerve  seized  and  cut  squarely  off. 
The  attachments  of  the  oblique  muscles  and  the  remaining  tissue  which  maj^  cling 
to  the  e3'eball  are  then  severed.  Subsequently  the  conjunctival  wound  is  closed 
with  a  few  interrupted  sutures. 

Hemorrhage  is  usually  not  severe,  and  is  readily  controlled  by  pressure.  After 
freely  irrigating  the  socket  with  a  bichlorid  solution,  it  may  be  dusted  with  iodoform 
and  a  full  antiseptic  dressing  should  be  applied.  In  place  of  general  anesthesia, 
local  anesthesia,  by  means  of  retrobulbar  injections  (see  page  658),  is  preferred  by 
some  surgeons. 

The  operation  just  described  is  sometimes  known  as  Bonnet's 
method.  The  eye  may  also  be  removed  by  what  is  known  as  the 
Vienna  method,  as  follows: 

The  only  instruments  necessarj' are  a  pair  of  strong  scissors  and  toothedforceps. 
The  tendon  of  the  internal  rectus,  together  with  the  overlying  conjunctiva,  is  seized 
in  one  grasp  with  the  forceps.  It  is  then  divided  and  the  stump  retained  in  the 
grasp  of  the  instrument.  With  the  scissors  the  inferior  rectus  and  superior  rectus 
are  now  divided,  together  with  the  overlying  conjunctiva.  The  globe  is  drawn 
forward,  rotated  outward,  and  the  optic  nerve  divided.  The  operation  is  con- 
cluded by  cutting  the  external  rectus  and  the  two  oblique  muscles  close  to  the 
globe.  This  operation  can  be  rapidly  performed.  It,  however,  does  not  always 
yield  as  good  a  stump  as  the  more  slowly  performed  procedure  peviously  described 

The  methods  of  enucleation  just  described  were  almost  universally 
employed  until  recent  j'ears.  The  technic,  however,  has  been  mate- 
rially improved,  chiefly  by  the  various  methods  of  suturing  the  tendons 
to  the  conjunctival  bed  to  prevent  their  retraction.     Suker  sutures 


710  OPERATIONS 

the  severed  ends  of  the  recti  muscles  one  to  the  other,  after  which 
the  conjunctiva  from  above  and  ))olow  is  broufiht  over  the  muscle- 
stump  and  fastened  with  a  continuous  suture,  which  also  attaches  the 
conjunctival  covering  to  the  muscle-stump.  H.  Schmidt  secures 
each  rectus  tendon  with  a  catgut  suture  and  makes  a  slit  in  the 
conjunctiva  over  each  muscle,  in  which  the  divided  conjunctiva  is 
fastened.  The  conjunctiva  is  brought  together  with  a  continuous 
suture.  Priestle}'  Smith  pinches  up  a  narrow  horizontal  fold  of  the 
conjunctiva  over  the  internal  rectus,  so  as  to  include  the  subjacent 
connective  tissue  and  muscle,  and  carries  a  black  silk  suture  through 
these  structures  with  a  curved  needle,  the  suture  being  tied  firmly,  but 
not  too  tightly.  In  a  similar  manner  the  other  straight  muscles  are 
attached,  after  which  the  enucleation  is  carried  out  in  the  usual  man- 
ner and  the  conjunctival  aperture  closed  with  one  or  more  vertical 
sutures.  Frederic  Krauss  has  devised  a  more  elaborate  procedure 
whereby  the  relations  of  the  ocular  muscles  to  Tenon's  capsule  are 
preserved  and  the  rotations  of  the  stump  increased. 

Freeland  Fergus'  method  of  enucleation  is  as  follows: 

The  conjunctiva  is  divided  freely  over  the  external  rectus  so  as  to  expose  thor- 
oughly that  muscle.  As  soon  as  this  is  done,  one  blade  of  the  scissors  is  passed 
beneath  the  muscle  and  it  is  divided,  a  small  portion  of  its  tendon  being  left 
attached  to  the  sclera.  This  portion  is  taken  hold  of  with  the  forceps  and  the 
eye  is  gently  rotated  toward  the  inner  canthus.  When  in  this  position  the  optic 
nerve  is  severed.  After  the  division  of  the  nerve  the  movement  of  rotation  is  con- 
tinued and  all  the  other  tissues  are,  as  they  come  in  view,  resected  as  closely  as 
possible  to  the  sclera.  A  few  snips  of  the  scissors  suffice.  The  wound,  which 
is  always  neat,  may  be  closed  with  or  without  the  insertion  of  a  gold  ball,  or  with 
or  without  suturing  together  of  the  muscles,  as  recommended  in  the  following 
paragraph. 

The  author  has  operated  in  the  following  manner  with  satisfactory 
results : 

The  conjunctiva  is  divided  as  close  as  possible  to  the  corneal  margin ;  each  rectus 
tendon  is  next  seized  with  forceps,  separated  from  the  sclera,  and  drawn  forward  to 
the  edge  of  the  cut  conjunctiva,  where  it  is  fastened  with  a  black  silk  suture.  The 
eyeball  is  next  enucleated  in  the  ordinary  maiuier.  hemorrhage  being  checked  by 
packing  the  cavity  with  a  small  wad  of  sterilized  gauze.  Finally,  after  removal  of 
the  packing,  the  edges  of  the  conjunctiva  are  united  with  interrupted  sutures 
which  are  generally  i)laced  in  a  horizontal  direction,  and  which  also  include  the 
capsule  of  Tenon.  The  us\ial  dressing  is  applied,  both  eyes  being  bandaged  for 
twenty-four  hours. 

The  effect  of  this  operation,  whereby  each  rectus  tendon  is  "ad- 
vanced" to  the  margin  of  the  conjunctiva  and  jirevented  from  retract- 
ing, is  to  give  a  movement  to  the  conjunctival  bed  very  nuich  greater 
than  that  whicii  is  secured  after  the  ordinary  enucleation. 

Accidents. — (a)  Hcinorrluujc  Occasionally  .severe  hemorrhag(»  oc- 
curs tlwring  th(;  enucleation  of  an  eyeball,  sometimes  eau.seii  by  an 
anomalous  distribution  of  the  vessels.  If  necessary,  the  orbit  can  be 
packed  with  antiseptic  gauze,     '{'he  ti.ssues  of  the  orl)it  u\i\\  become 


ENUCLEATION    OF    THE    EYEBALL  711 

very  much  infiltrated  with  blood  and  puff  out  in  an  alarming  manner. 
The  blood-clot,  however,  will  gradually  be  absorbed,  and  no  harm 
results. 

(6)  Perforation  of  the  Sclera. — -Sometimes,  especially  in  a  ball  hav- 
ing very  thin  walls,  the  sclera  is  punctured  in  the  endeavor  to  cut  the  optic 
nerve.  This  simply  complicates  the  operation,  because  it  is  more  diffi- 
cult to  remove  a  collapsed  ball  than  one  which  is  distended.  Should 
the  operator  be  so  unfortunate  as  to  cut  through  the  sclera  and  leave  a 
portion  of  it  remaining  behind,  he  must  proceed  to  search  for  the  frag- 
ment, which  can  be  picked  up  with  forceps,  and  cut  it  off,  together  with 
the  nerve. 

(c)  Consecutive  or  Secondary  Hemorrhage. — Occasionallj'  a  consecu- 
tive or  secondar}^  hemorrhage  occurs  after  enucleation.  The  bandages 
should  be  removed,  the  lids  separated,  the  blood-clot  removed,  the 
orbit  irrigated  with  an  antiseptic  fluid,  and,  if  pressure  fails  to  stop  the 
hemorrhage,  a  packing  of  antiseptic  gauze  should  be  inserted.  Exces- 
sive hemorrhage  in  hemophilic  subjects  has  been  checked  by  the  intra- 
venous injection  of  normal  blood-serum. 


Fig.  352. — Average  artificial  eye  or  shell.  Fig.  353.^ — Solid  artificial  eye. 


The  after-treatment  of  an  enucleation  consists  in  placing  the  patient 
in  bed,  certainly  for  the  first  few  days.  No  severe  pain  ought  to  follow 
an  enucleation,  and  decided  headache,  elevation  of  temperature,  and 
restlessness  may  indicate  meningeal  complication.  In  a  certain  num- 
ber of  instances  meningitis  has  followed  the  operation,  especially  when 
it  has  been  performed  on  an  eye  within  which  suppuration  is  taking 
place.  Under  modern  methods  of  operating  and  with  antiseptic  pre- 
cautions this  accident  is,  fortunateh',  a  rare  one. 

Insertion  of  Artificial  Eyes. — An  artificial  ej'e  may  be  inserted  as 
earlj'  as  the  second  or  third  week  after  an  enucleation  of  the  eye;  in- 
deed, some  operators  insert  it  at  a  much  earlier  date.  For  the  first 
week  or  two  the  artificial  eye  should  be  smaller  than  that  which  is  a 
perfect  match  for  the  opposite  side.  The  eye  maj'  then  be  exchanged 
for  one  which  in  size  is  as  nearlj^  as  possible  a  match  for  the  fellow-eye. 
At  first  the  eye  may  be  worn  for  several  hours  at  a  time.  Soon  it  can  be 
worn  all  day,  but  it  never  should  be  allowed  to  remain  in  the  socket 
during  the  night.  It  is  not  necessary  to  keep  an  artificial  eye  in  water 
during  the  night.  It  should  be  washed  with  a  little  alcohol  and  water 
and  allowed  to  dry. 

In  order  to  insert  an  artificial  eye,  the  upper  e3'elid  is  seized  between 
the  fingers  of  the  left  hand  and  drawn  gently  down  and  out,  and  the 
larger  end  of  the  shell  is  inserted  vertically  beneath  it,  then  brought  to  a 
horizontal  direction,  while  at  the  same  time  the  lower  lid  is  pulled 
down,  when  the  shell  slips  into  place.     In  order  to  remove  an  artificial 


>v! 


712  OPERATIONS 

eye,  the  head  of  a  large  pin  is  inserted  beneath  its  lower  margin,  the 
lower  lid  being  at  the  same  time  depressed,  while  the  eye  is  tipped  up- 
ward and  forward,  when  the  pressure  of  the  upper  lid  will  force  it  out. 
Verj'  soon  patients  become  exceedingly  expert  in  taking  out  and  intro- 
ducing: artificial  eyes,  and  do  not  require  the  aid  of  a  pin  in  making  the 
manipulation  just  described.  Owing  to  failure  to  care  properly  for 
the  socket  it  may  become  infected  with  the  development  of  much 
mucopurulent  or  purulent  secretion.  It  is  a  troublesome  condition. 
Bichlorid  of  mercury  and  boric  acid  lotions  may  be  tried.  If  the 
pneumococcus  is  present  optochin  (2-5  per  cent.)  and  mercurophen 
(1:8000)  are  useful.  Dichloramin-T  in  eucalyptol  is  excellent. 
Lawson's  recommendation  of  flavine  (proflavine)  in  septic  wounds 
and  some  forms  of  purulent  conjunctivitis  suggests  its  trial  in  this 
condition,  the  strength  of  the  solution  being  1:1000. 

One  of  the  chief  objections  to  the  shell-shaped  prosthesis,  or  artifi- 
cial eye,  is  the  fact  that  in  its  hollow  under  surface  tears  and  mucus  may 
accumulate,  while  its  thin  edges  may  bruise  the  conjunctival  bed.  To 
obviate  this  difficulty  the  so-called  "reformed  artificial  eye"  has  been 
introduced,  largely  through  the  efforts  of  Professor  Snellen,  which  con- 
sists of  a  double-walled  shell,  or  sometimes  of  a  solid  ej'e,  the  smooth 
rounded  contour  of  which  neutralizes  the  objections  to  the  thin  edges 
of  the  old-fashioned  shells.  The  movements  of  an  eye  of  this  charac- 
ter, placed  in  the  socket  after  a  properh'  performed  enucleation  with  ^ 
suture  of  the  tendons  or  implantation  of  a  gold  sphere  in  Tenon's  cap- 
sule, are  nearly  as  extensive  as  those  which  follow  Mules'  operation. 

Instead  of  the  operation  of  enucleation,  certain  substitutes  have 
been  proposed,  the  most  important  of  which  are: 

Evisceration  of  the  Eyeball. — This  consists  in  an  evacuation  of 
the  contents  of  the  eye,  the  sclera  being  unmolested,  and  closure  of 
the  scleroconjunctival  wound  with  sutures,  thus  forming  a  movable 
stump  for  the  artificial  eye. 

The  instruments  required  for  the  operation  are  a  speculum,  fixation 
forceps,  a  narrow  knife,  a  pair  of  scissors,  and  an  evisceration  spoon. 
It  is  perf(jrme(l  as  follows: 

The  speculum  bein^  intioduced,  tlie  conjunct;^va  is  loosenctl  nround  the  cornea; 
the  anterior  clianiher  is  transfixed  with  the  knife  on  a  k'vel  with  tlie  horizontal 
meridian,  the  lower  portion  of  the  cornea  separated,  the  flap  seized  with  forceps,  and 
the  remainder  of  the  cornea  cut  away  at  the  corneoscleral  margin.  With  the  evis- 
ceration scoop  the  contents  of  the  glol)e  are  thorounldy  and  cleanly  evacuated. 
The  cavity  of  the  globe  is  wiped  out  witii  sterilized  cotton-wool,  and  all  bleedinj;  is 
stopped,  "^ihe  edges  of  the  conjunctiva  are  united  by  means  o(  a  suture  siuular  to 
the  string  which  draws  shut  a  tobacco-pouch — a  suture  sometimes  called  the 
lofidccu-poiich  fiutrirc,  or  by  interrupted  sutures.  These  may  include  the  conjunc- 
tiva alone,  unless  this  is  very  much  macerated,  when  it  may  i)e  necessjiry  to  include 
the  sclera.  The  author  is  accustomed  to  suture  both  the  sclera  and  the  conjunctiva. 
'I'he  evisceration  may  be  accomplished  without  sacrificing  the  cornea  proviiled  thb* 
membrane  is  not  iiifecrted  (OilTord). 

( 'oiisidriahlc  ]);iin  may  follow  Ihr  opciat  ion,  logclhcr  with  t'licnia 
and  swelling  of  the  siinounding  1  issues.      In  ordt-r  to  a\'oid  this,  it  has 


EVISCERATION  OF  THE  EYEBALL  713 

been  recommended  to  introduce  a  horse-hair  drain,  and  Prince  has 
suggested  wiping  out  the  cavity  with  carboUc  acid  in  order  to  allay  the 
pain. 

The  chief  indication  for  evisceration  is  panophthalmitis  (see  also 
page  387),  although  it  may  also  meet  the  indications  which  are  men- 
tioned below  in  connection  with  Mules'  operation.  Evisceration  is 
contraindicated  by  sympathetic  inflammation  or  irritation,  malignant 
disease,  and  much  shrunken  eyeballs.  Although  the  stump  after  evis- 
ceration is  primarily  more  voluminous  than  that  which  is  secured  after 
an  enucleation,  subsequent  shrinking  of  this  stump  ultimately  renders 
the  cosmetic  effect  of  the  operation  no  better  than  that  which  is  secured 
by  a  properly  performed  enucleation,  while  its  inconveniences  are 
much  greater.  If  Gifford's  plan  is  pursued  (simple  evisceration) ,  that 
is,  without  keratectomy,  the  stump  is  more  voluminous  than  after  the 
ordinary  evisceration. 

As  a  substitute  for  evisceration  W.  T.  Lister  has  advocated  and 
practised  the  enucleation  of  a  septic  eye  with  this  modification,  namely, 
that  a  fringe  of  sclera  about  10  mm.  in  width  is  allowed  to  remain  and 
surround  the  optic  herve  entrance,  avoiding,  therefore,  opening  the 
optic  nerve  sheath  and  the  danger  of  conveying  infection  through  this 
route. 

Evisceration  of  the  Eyeball,  with  Insertion  of  an  Artificial 
Vitreous. — Mules'  Operation. — Mules  modified  the  operation  of 
evisceration  by  the  introduction  of  a  glass  ball  into  the  cavity  of  the 
sclera.     The  operation  is  performed  as  follows: 

After  general  anesthesia  a  stop  speculum  is  introduced,  and  the  conjunctiva  dis- 
sected from  the  corneoscleral  attachment  in  all  directions  to  the  equator  of  the  ball 
without  disturbing  the  muscles.  The  cornea  and  1  mm.  of  the  scleral  margin  are 
removed  in  the  manner  described  under  evisceration.  Next  the  contents  of  the 
globe  are  emptied  by  anj-  convenient  method,  a  small  evisceration  scoop  being  a 
satisfactory  instrument.  Great  care  must  be  taken  to  remove  the  entire  contents, 
leaving  a  perfectly  clean,  white  sclera.  Hemorrhage  is  controlled  by  packing  the 
scleral  cavity  with  sterilized  gauze,  and  by  frequently  irrigating  it  with  a  tepid 
solution  of  bichlorid  of  mercury  (1  :  5000).  A  glass  or  gold  sphere  (gold  is  prefer- 
able), of  such  size  that  it  may  be  introduced  within  the  scleral  cup  without  difficulty, 
is  selected,  its  introduction  being  facilitated  by  slitting  the  sclera  vertically  for 
about  4  mm.  at  the  upper  and  lower  margins  of  the  opening.  The  introduction  of 
the  sphere  is  further  facilitated  by  the  use  of  an  instrument  specially  devised  by 
Mules  for  this  purpose.  The  concluding  steps  of  the  operation  consist  in  stitching 
the  sclera  vertically,  the  conjunctiva  horizontally,  and  applying  a  full  antiseptic 
dressing..  The  patient  should  be  confined  to  bed  for  at  least  four  or  five  days. 
Considerable  reaction  may  follow,  and  marked  chemosis  of  the  conjunctiva. 
This  may  be  controlled  by  the  continuous  apphcation  of  cold,  and  probably  be 
avoided  by  not  removing  the  bandage  for  forty-eight  or  even  seventy-two  hours. 
Mules  recommended  that  the  sutures  should  be  of  catgut;  the  author  prefers  silk 
sutures. 

Victor  Ray  has  modified  this  operation  in  that  after  evisceration  of  the 
scleral  contents  he  removes  from  within  a  circular  piece  of  the  sclera,  20  mm.  in 
diameter,  which  includes  the  entrance  of  the  optic  nerve  and  ciliary  nerves  and 
vessels  and  fills  the  cavity  with  fat  instead  of  a  gold  ball.  In  like  manner, 
Dimitry  forms  a  posterior  window  in  the  sclera,  but  uses  a  gold  ball  as  in  the 
ordinary  Mules'  operation. 


714  OPERATIONS 

The  chieiindications ioT  this  operation  arc  ruptured  or  injured  eye- 
balls, provided  the  sclera  is  not  too  much  lacerated,  and  the  accident 
of  recent  date;  staphyloma  of  the  cornea  and  sclera,  or  complete 
leukoma;  absolute  glaucoma;  buphthalmos;  and  non-traumatic  irido- 
cj'clitis.  The  chief  contniinflications  are  suppuration  of  the  eyeball; 
morbid  growths;  much  shrunken  eyeballs,  the  contents  of  which  have 
undergone  bony  or  calcareous  change;  sympathetic  ophthalmitis,  sym- 
pathetic irritation,  and  pathologic  conditions  of  the  ej'eball  which  are 
likeh'  to  produce  either  of  the  last-named  affections;  extensive  injuries 
of  the  eyeball,  with  much  bruising  and  laceration  of  the  sclera;  dacryo- 
cystitis; and  ocular  conditions  demanding  enucleation  or  its  equivalent 
in  very  old  persons. 

Implantation  of  an  Artificial  Globe  in  Tenon's  Capsule  After  Re- 
moval of  the  Eyeball  {F'rost-Lang  Operation). 

The  eyeball  is  enucleated  in  the  manner  already  described,  and,  after  all  bleed- 
ing has  been  checked,  a  glass  or  gold  (gold  is  preferable)  ball  is  inserted  within 
Tenon's  capsule.  The  size  of  this  ball  should  not  be  less  than  14  mm.  in  diameter 
(Greenwood  insists  it  should  be  18-20  mm.  in  diameter)  and  the  capsule  should  be 
carefully  sewed  over  it  with  fine  silk  sutures.  It  is  the  practice  of  some  surgeons  to 
include  the  sphere  within  the  grasp  of  the  recti  muscles  by  stitching  the  superior 
rectus  to  the  inferior  rectus  by  means  of  a  mattress  suture  and  the  lateral  recti  by  a 
similar  suture.  This  plan  apparently  possesses  no  material  advantage,  provided  the 
muscles  are  secured  in  the  manner  described.  In  place  of  interrupted  stitches  a 
purse-string  suture  m&Y  be  used,  the  important  point  being  that  the  capsule  shall 
be  sewed  first  over  the  ball  and  the  conjunctiva  over  the  ball  thus  enclosed.  The 
conjunctival  sutures  may  be  placed  in  a  transverse  direction  or  vertically  (Green- 
wood prefers  the  latter  position).  The  suture  line  should  be  painted  with  a  5  per 
cent,  solution  of  iodin  or  1  :  1000  lotion  of  flavine  (Law.son).  The  after  treatment 
does  not  differ  from  that  accorded  to  an  enucleation;  the  reaction  is  usually  very 
slight.  If  great  care  is  taken  to  apply  the  sutures  (some  surgeons  prefer  fine  catgut) 
in  the  manner  described,  extrusion  of  the  ball  is  most  uncommon. 

This  operation  may  replace  ordinary  enucleation  in  all  cases  except  where 
sympathetic  ophthalmia  is  threatened  or  present  or  the  eyeball  is  .septic  (panoph- 
thalmitis); it  is  usually  not  performed  in  the  presence  of  an  intra-ocular  growth. 
The  cosmetic  results  are  excellent.  Paraffin  spheres  have  been  recommended  in 
place  of  glass  or  gold  balls;  they  possess  no  advantage  in  this  respect.  Silver  coated 
balls  must  not  be  <ised;  they  undergo  disintegration  as  the  result  of  oxidation. 

Implantation  of  Cartilage. — Many  surgeons  prefer  natural 
tissues  in  contrast  to  metallic  or  glass  i)r()stlu>sis.  Transfcrnnl  carti- 
lage establishes,  it  is  said,  fresh  comnmnications  with  the  blood- 
vessels in  its  vicinity,  and  becomes  fixed  to  the  capsule  in  recent 
enucleations.  Even  if  the  cartilage  after  imi)lantati()n  is  transformed 
into  a  si)ecies  of  fibrous  tissue,  it  is  believed  that  the  i-osinetic  result 
is  notdisturbed. 

For  the  purpo.se  of  making  cartilage  im|>lantation  gfiu-rally  the  .seventh  or 
eighth  rib  is  selected  and  the  glol>e  of  cartilage  removed  with  a  trei)hine  of  suoli  size 
as  is  suited  to  the  conditions.  The  cartilage  having  been  mtroduced  within 
Tenon's  capsule,  it  is  sutured  to  the  inside  or,  if  possible,  the  four  straight  muscles 
are  attached  by  means  of  sutures  to  this  cartilage  sj)lu're;  the  rest  of  the  operation 
proceeds  as  has  already  been  described.  It  him  been  stated  that  such  gr.-ifts  may 
be  used  even  in  the  presence  of  septic  eyes  or  septic  sockets.     The  .-lullior  h.-us  no 


FAT  IMPLANTATION  INTO  TENON 's   CAPSULE  715 

experience  in  this  regard,  but  doubts  the  propriet}^  of  an  implantation  in  a  septic 
socket. 

In  place  of  human  cartilage  it  is  the  practice  of  some  surgeons,  notably  Magitot, 
to  use  formalized  cartilage  taken  from  a  calf  or  lamb  rib.  This  is  placed  in  formol, 
10  per  cent.,  for  three  days,  and  afterward  freed  from  the  formol  by  successive 
washings  in  sterile  water.  It  is  most  important  that  there  shall  be  a  thorough 
removal  of  all  traces  of  the  formol  before  the  cartilage  is  implanted,  which  can  be 
shaped  to  any  size  that  is  required  for  the  purpose  of  the  implantation. 

Terrien  recommends  a  graft  of  cartilage,  generally  rib  cartilage,  1.5  cm.  in 
length,  to  which  the  tendons  of  the  rectus  muscles  are  sutured.  In  default  of  the 
graft  prosthesis  he  generally  improved  the  appearances  by  using  artificial  stumps 
of  hard  ebonite  shell  in  an  envelope  of  soft  India-rubber,  which  was  molded  to  the 
bottom  of  the  conjunctival  sac,  or  molds  of  wax  were  placed  behind  the  artificial 
eye. 

Fat  Implantation  into  Tenon's  Capsule. — This  operation,  originally 
proposed  and  practised  by  Barraguez,  came  into  prominent  notice 
after  Bartels  called  attention  to  the  operation  in  1908. 

The  eyeball  is  enucleated,  the  recti  muscles  being  secured  in  the  manner 
already  described.  A  mass  of  fat  taken  from  the  abdominal  wall  is  inserted 
into  Tenon's  capsule  so  as  to  fill,  but  not  to  overstretch,  it.  The  muscles  are 
sutured  crosswise  or  by  means  of  a  purse-string  suture,  and  next  the  cut  conjunctiva 
is  united  with  stitches.  Either  catgut  or  silk  may  be  emplojed.  The  cosmetic 
result  is  good. 

A  number  of  modifications  of  this  operation  have  been  suggested  in  the  amount 
of  fat  to  be  inserted  and  in  the  management  of  the  muscles.  The  mass  of  fat  may 
be  covered  with  fascia  lata  over  which  the  muscles  are  secured  in  the  usual 
manner.  B.  W.  Key  has  devised  an  elaborate  technic  whereby  he  strives  to  obtain 
a  healthy  and  permanent  growth  of  fat  within  Tenon's  capsule  and  to  attach  the 
muscles  in  such  a  manner  that  the  stump  shall  have  decided  rotary  motion. ' 

Implantation  of  a  Glass  or  Gold  Ball  into  the  Orbit  after  Remote 
Enucleation  of  an  Eyeball. — L.  W.  Fox  operates  as  follows : 

If  the  operation  is  to  be  performed  on  the  right  orbit,  the  eyelids  are  separated 
by  a  speculum,  the  conjunctiva  is  grasped  up  and  in  above  the  inner  canthus,  and 
the  tissues  are  well  pulled  out.  Next,  a  Beer's  knife  or  curved  keratome  is  passed 
through  the  tissues  somewhat  obUquelj^  and  well  down  into  the  orbit,  and  an  open- 
ing made  large  enough  for  the  insertion  of  the  globe  behind  the  tissues.  This 
opening  may  be  enlarged  with  curved  scissors  to  the  desired  size.  When  ready,  a 
gold  ball  is  inserted  through  the  opening,  which  is  closed  with  two  stitches  and 
over  which  a  shell  is  placed,  modeled  after  an  artificial  eye.  The  eyelids  are  then 
closed  over  this  shell,  which  is  left  in  place  for  twenty-four  hours.  The  stitches  are 
taken  out  on  the  third  day.  If  the  operation  is  to  be  performed  on  the  left  orbit, 
the  incision  is  made  up  and  out  above  the  external  rectus  muscle  and  the  dissection 
carried  out  as  above  described.  After  heaUng,  the  artificial  eye  is  inserted  in  the 
usual  manner,  and,  naturally,  the  support  of  the  implanted  globe  improves  the 
cosmetic  result.  A  comparatively  large  percentage  of  these  balls  escape,  or  are 
extruded;  moreover,  the  sphere  may  leave  its  central  position,  causing  the  overlying 
glass  eye  to  be  turned  in  some  eccentric  direction. 

To  obviate  this  a  method  may  be  practised  as  follows:  The  conjunctiva  is 
incised  in  a  horizontal  direction  and  dissected  from  the  underlying  tissue.  Tenon's 
capsule  is  identified  and  freed,  and  within  its  space  the  ball  is  placed.  If  possible 
the  ocular  muscles  are  found  and  secured  in  the  manner  already  described,  the 
whole  procedure  being  a  replica  of  a  primary  implantation. 

^  Canadian  Medical  Quarterly,  Maj-^,  1919. 


710 


OPERATIONS 


In  place  of  a  gold  or  glass  sphere  cartilage  may  be  used,  or  fat  wrapped  in 
fascia  lata.  The  insertion  of  sponge-grafts,  glass  balls  wrapped  in  a  sponge-layer, 
or  paraffin  sphere  have  been  rocominendcd,  in  primary  and  late  implantations, 
l)ut  possess  no  advantage  over  those  which  have  been  described;  as  previously 
noted  silver  balls  are  not  advisable,  as  they  undergo  oxidation  within  the  tissues. 

Opticociliary  neurotomy  and  neurectomy  have  been  employed  as 
substitutes  for  enucleation,  and  are  still  performed  by  some  surgeons, 
but  in  the  opinion  of  the  author  they  are  rarely  to  be  recommended. 

Removal  of  Metallic  Foreign  Bodies  from  the  Interior  of  the 
Eye. — For  this  purpose,  as  has  already  been  recorded  on  page  321 ,'  a  giant 
magnet  may  be  employed  (the  Haab  pattern),  and  the  bod^'  drawn 
into  the  anterior  chamber,  or,  having  been  properly  localized  by 
means  of  the  x-rays,  it  is  removed  by  means  of  a  large  magnet  (the 


Fig.  .354. — Showing  the  use  of  the  large  magnet  in  extracting  au  iron  spicule  from  the 

eye  (Haah). 

Sweet  model,  Lancaster  model),  through  a  suitably  placed  scleral  in- 
cision which  directly  overlies  the  position  of  the  metal.  The  exten- 
sion-pcjint  of  the  inagiiet,  howev(M',  does  not  enter  the  sclera. 

Haab's  Operation.  -This  may  be  performed  as  follows,  according 
to  this  distinguished  operator's  directions: 

After  the  usual  aseptic  preparations  and  thorougli  cocain  anestliesia  of  the 
eye,  the  operator  assumes  one  of  the  two  positions  shown  in  tlie  accoiupanying 
figures. 

In  tlie  majority  of  ca.ses — that  is,  in  all  tiiose  in  whirh  a  siiiall-  to  a  medium- 
sized  sphiitor  is  |)iobal»ly  jircscnt — the  cenlt'r  of  tlie  cornea  sliuuld  l)e  placeil  exactly 
opposite  tlie  pole  of  the  inagnct.  If  the  j)resence  of  a  large  sjjlinter  is  suspected  the 
]>(>[('  of  the  magnet  should  first  be  allowed  to  act  at  some  distance  from  the  eye. 
The  patient  is  told  to  look  in  the  direction  of  the  pole  of  the  magnet.  The  first 
closure  of  the  current  iiuiy  bring  the  foreign  boily  behind  the  iris.  If  it  does  not, 
the  current  must  be  !<'|)catedlv  opencij  and  clo.si'd.  If  now  thei-e  is  no  bulging  of 
the  iris,  more  lateral  portions  of  the  cornea  art-  successively  i)rought  opposite  the 


REMOVAL  OF  METALLIC  FOREIGN  BODIES  FROM  THE  EYE    717 


pole,  but  the  region  of  the  cihary  body  must  be  scrupulously  avoided.  To  draw 
the  splinter  forward,  from  behind  the  iris,  through  the  pupil  into  the  anterior 
chamber  is  not  alwaj^s  an  easy  matter,  although,  if  it  is  smooth,  it  usually  comes 
without  difficulty.  Occasionally  iridectomy  is  necessary,  although  Haab  has  not 
found  this  requisite  in  his  personal  experience.  According  to  Lang's  suggestion,  a 
smooth  steel  spatula,  attached  to  the  magnet,  may  be  carried  through  a  corneal 
incision  behind  the  iris  where  the  splinter  is  lodged.  In  uncomplicated  cases  after 
the  splinter  reaches  the  anterior  chamber  it  may  be  removed  through  a  suitable 
corneal  incision  by  introducing  the  extension  point  of  a  small  magnet,  although 
Haab  himself  finishes  the  operation  with  the  large  magnet.  Each  case  must  be 
carefully  considered  and  the  technic  varied  according  to  the  conditions. 

The  anterior  route  was  the  operation  of  choice  among  British  surgeons  dur- 
ing the  war,  and  is  of  many  of  our  own  surgeons  in  army  and  civilian  practice. 
The  technic  is  closely  similar  to  the  one  just  described.    The  magnet's  extension  point 


Fig.  355. — Showing  the  use  of  the  large  magnet  in  extracting  an  iron  spicule  from  the 

eye  (Haab). 

is  brought  in  contact  with  the  pole  of  the  cornea,  the  current  alternately  turned  on 
and  off,  in  order  to  draw  the  body  through  the  suspensory  ligament  of  the  lens  into 
the  posterior  aqueous  chamber.  When  the  iris  is  seen  to  bulge,  indicating  the 
presence  of  the  body  behind  it,  the  current  is  turned  off  and  the  direction  of  the  eye 
so  changed  that  the  full  force  of  the  magnet  when  the  current  is  again  turned  on 
shall  be  parallel  to  the  surface  of  the  lens.  The  body  having  been  drawn  gradually 
into  the  anterior  chamber,  a  small  opening  is  made  with  a  narrow  keratome  about 
3  mm.  below  the  hmbus,  and  no  aqueous  spilled  if  possible.  The  extension  point 
of  the  magnet  is  directed  next  outside  of  the  cornea  over  the  foreign  body,  which  is 
coaxed  along  the  posterior  surface  of  the  cornea  into  the  corneal  incision,  through 
which  it  is  drawn  with  the  aid  of  a  small  hand  magnet. 

If  the  scleral  route  is  chosen,  at  the  point  of  election,  as  determined  bj^  x-ray 
localization,  after  raising  a  suitable  conjunctival  flap,  a  small  meridianally  placed 
incision  is  made  through  the  sclera,  to  which  the  magnet  is  appUed,  and  through 
which,  while  it  is  retracted  with  small,  non-magnetic  retractors,  the  body  is  with- 
drawn.    The  conjunctival  flap  is  next  replaced  and  sutured  into  position. 

In  the  presence  of  a  conspicuous  wound  of  entrance  indicating  a  large  foreign 
body,  its  removal  along  the  track  of  the  wound  is  the  usual  procedure.  The 
treatment  of  eyes  from  which  foreign  bodies  have  been  extracted  is  the  same  as 
that  which  has  been  recommended  for  scleral  wounds  (pages  318  -322). 


718 


OPERATIONS 


Fig.  356. — Spiiidle-cell  sarcoma  of  tlie  orbit  whicli  was  removed,  with  preservation  of 
the  functions  of  the  eye,  through  an  incision  beneath  the  entire  orbital  arch. 


'' 


I'm    '.iC>7. — itoHiilt  iifliT  ri'niovul  of  sarcoma  of  orbit. 


REMOVAL    OF    TUMORS    AND    CYSTS    FROM    THE    ORBIT       719 

Extirpation  of  the  Whole  Contents  of  the  Orbit  (Exentera- 
tion).— This  is  the  operation  necessary  in  certain  cases  of  mahgnant 
disease. 

The  eyeball  having  been  removed  in  the  ordinary  waj-,  an  incision  is  made 
through  the  outer  commissure  to  the  edge  of  the  orbit.  The  lids  having  been 
widely  separated,  the  tissues  back  of  them  and  the  periosteum  within  the  orbital 
margin  are  divided  with  a  scalpel.  Next,  the  periosteum  is  separated  to  the  apex 
of  the  orbital  cavity,  where  the  entire  mass  of  tissue  is  detached  with  strong  curved 
scissors  or  other  suitable  instrument.  Bleeding,  which  is  sometimes  considerable, 
may  be  checked  bj'  packing  with  the  surgical  gauze  or  pressing  surgical  wax 
against  the  bleeding  area  or,  if  necessary,  by  the  actual  cautery.  The  cavitj'  is 
looseljr  packed  with  iodoform  or  ordinary  sterile  gauze,  one  strand  of  which  may  be 
left  at  the  outer  commissure  for  drainage.  Next,  the  ciliarj^  borders,  including  all 
hair-follicles,  are  removed,  and  the  lids,  thus  prepared,  are  sutured  together  up  to  the 
point  where  the  gauze  strand  protrudes.  The  packing  should  be  removed  at  the 
end  of  twenty-four  hours.  In  favorable  cases  the  lid-skin  will  be  retracted  inward 
and  completely  line  the  socket.  Thiersch  grafts  are  also  used  for  this  purpose. 
It  may  happen  that  the  eyeball  is  so  involved  with  the  malignant  disease  which  is 
present  that  its  extirpation  as  the  first  step  of  the  operation  is  not  feasible.  The 
operator  then  proceeds  as  before  described,  removing  the  ej-eball  with  the  entire 
mass  of  tissue.  If  the  lids  are  not  sutured  in  the  manner  described,  as  considerable 
contraction  of  the  socket  takes  place,  its  granulating  surface,  as  stated,  may  be 
covered  with  epidermic  grafts.  Many  attempts  to  adjust  a  large  prosthesis 
have  been  made. 

Removal  of  Tumors  and  Cysts  from  the  Orbit. — Tumors  in  the 
anterior  portions  of  the  orbit  ma}'  be  reached  by  an  incision  similar  to 
that  already  described  in  connection  with  deep-seated  purulent  pockets 
(see  page  635),  and  the  growth  removed  by  an  ordinary  dissection. 
Occasionally,  in  favorable  situations,  such  growths  may  be  reached  bj^ 
a  dissection  through  the  conjunctiva. 

If  the  growth  is  an  angioma,  and  is  encapsulated,  it  ma}'  often  be 
removed  in  similar  manner  by  a  slow  dissection,  without  much  loss 
of  blood.  If  non-encapsulated,  and  especially  if  it  protrudes  and  in- 
volves the  skin  of  the  hd  and  brow,  it  is  a  much  more  difficult  pro- 
cedure. To  a  certain  extent  the  hemorrhage  can  be  controlled,  as 
Knapp  suggested,  by  pushing  a  horn  spatula  beneath  the  upper  lid, 
between  the  ej'eball  and  the  orbit,  which  may  be  manipulated  to  act 
as  a  controller  of  hemorrhage,  while  the  dissection  proceeds  from  the 
skin  surface.  Although  the  main  body  of  the  angioma  may  thus  be 
removed,  it  is  often  impossible,  without  sacrifice  of  too  much  tissue, 
to  extirpate  those  portions  of  it  which  involve  the  skin  of  the  eyelids 
and  e3'ebrow.  These,  however,  may  disappear  later,  or  may  be  treated 
b}'  electrolysis.  Recent  investigations  indicate  that  they  may  be  suc- 
cessfully treated  by  applications  of  liquid  air. 

Sometimes  encapsulated  sarcomas,  endotheliomas,  and  certain  non- 
malignant  growths,  especially  in  the  anterior  portion  of  the  orbit, 
may  be  reached  without  sacrificing  the  eyeball,  according  to  a  method 
advocated  b}'  Lagrange  and  H.  Knapp,  namely,  first  severing,  if,  for 
example,  the  growth  is  on  the  inner  side,  the  internal  and  perhaps  the 
inferior  rectus,  which  are  secured  with  threads,  next  separating  the 


720 


OPERATIONS 


conjunctiva,  and  gradually  dissecting  out  the  growth  through  the 
opening  thus  made.  After  controlling  the  hemorrhage  the  severed 
recti  muscles  are  sewed  in  place  exactly  as  in  the  operation  of  advance- 
ment. Again,  the  growth  may  be  reached  by  means  of  a  dissection 
which  begins  with  an  incision  which  extends  beneath  the  entire  length 
of  the  orbital  arch  and  is  continued  slightly  downward  and  outward 
along  the  outer  margin  of  the  orbit.  Should  it  become  necessary 
to  divide  an  ocular  muscle  it  can  first  be  secured  in  the  manner  just 
described.  This  operation,  carefully  performed,  in  suitable  cases,  re- 
places resection  of  the  temporal  wall  of  the  orbit  and  produces  much 
less  deformity  (see  Figs.  356,  357).  Orbital  cysts,  dermoids,  serous  or 
blood  cysts  are  treated  in  the  same  manner  as  growths,  the  dissection 
proceeding  either  through  an  incision  along  the  orbital  margin  or,  if 
conditions  are  favorable,  through  the  conjunctiva,  great  care  being 


Fig.  ;i58. 


— Psammosarcoma  of  orbit. 
(See  page  639.) 


Fig.  359. — Psammosarcoma  of  orlnt. 
Result  alter  operation;  eye  functions 
normal. 


taken  to  remove  every  particle  of  the  cyst  wall,  often  a  difficult  pro- 
cedure. In  some  instances  the  ej^st  elaboration  is  so  extensive  that 
the  eyeball  cannot  be  saved. 

Exostoses  and  osteomas  growing  from  (he  wall  of  the  orbit,  or 
pushing  their  way  into  it  from  the  ethmoidal  or  frontal  sinus,  may  be 
reached  by  an  ordinary  dissection  through  an  incision  along  the  orbital 
margin,  with  the  usual  precautions  to  avoid  the  pulley  of  tlie  superior 
obiitjue,  the  tendon  of  the  levator,  and  the  lacrimal  glaiid.  .\fter  the 
body  of  the  growth  is  fully  exposed,' it  may  be  cliisclcd  from  its  position 
in  the  ortiinary  manner  or,  if  it  is  very  dense  and  resisting,  its  base  may 
be  perforated  several  times  with  a  drill  suitably  attacheil  to  a  dental 
engine.  It  is  next  broken  from  its  position  with  a  stout  pair  of  forceps, 
all  rough  spicules  of  Ijoiic  carefull.N'  siiioothtMl  away,  and  the  wound 
closed.      (See  also  page  039.) 

Resection   of  the  Temporal  Wall  of  the  Orbit  (Krdnlrin's  Operation). — The 

opfniliun,  follouiiin   Ilanh's  dirrclions,  l)('^;iIl.s  liy  dividinn  tho  soft   pjirt.s  wilh  a 


i 


KRONLEIN  S    OPERATION 


721 


curved  incision  (Fig.  360),  which  should  be  about  7  cm.  in  length  in  adults  and  4  to 
5  cm.  m  children,  which  commences  above  the  supra-orbital  margin  and  describes 
a  gentle  curve  along  the  outer  edge  of  the  orbit  to  the  upper  edge  of  the  zygoma, 
where  it  is  bent  backward  and  ends  at  the  center  of  this  structure.  The  center  of 
this  curved  incision  should  bisect  a  horizontal  line  which  connects  the  outer  canthus 
with  the  outer  orbital  margin,  and  here  should  be  sufficiently  deep  to  expose  the 
opening  of  the  orbit,  while  above  and  below  only  the  skin  and  fascia  and  muscular 
layer  are  at  first  divided.  Next,  at  a  position  corresponding  to  the  central  portion 
of  this  incision,  a  strong  elevator  is  introduced,  with  which  the  periosteum  is 
separated  from  the  external  orbital  wall.  The  inferior  orbital  fissure  is  now  local- 
ized, and,  beginning  at  the  anterior  end  of  this  fissure,  the  bony  wall  of  the  orbit  is 
cut  through  with  a  chisel  or  with  an  electric  saw,  up  and  out  to  a  point  a  little  above 
the  external  angular  process  of  the  frontal  bone,  the  line  of  incision  being,  for  all 
practical  purposes,  along  the  suture  between  the  great  wing  of  the  sphenoid  and  the 
malar  bone,  and  outward  and  forward  over  the  external  surface  of  the  malar  bone 
in  a  line  above  the  insertion  of  the  zj-gomatic  arch.     Thus,  a  wedge-shaped  piece 


Fig, 


360. — Skin  incision  (curved  line)  and  bone  incisions  (heavy  lines)  in  Kronlein's 
operation  (Haab). 


of  bone  is  formed,  and  with  its  muscular  and  cutaneous  attachments  is  forced 
backward,  giving  free  access  to  the  orbit,  which  will  be  still  partly  covered  with  the 
periosteum.  The  latter  must  now  be  split  from  before  backward  and  separated 
with  retractors.  This  brings  into  view  the  external  rectus  muscle,  and,  if  necessary, 
this  may  be  divided  near  its  tendinous  insertion  after  the  introduction  of  sutures, 
with  which  later  the  divided  ends  are  united,  or  sometimes  the  muscle  may  be 
pushed  aside  and  the  dissection  continued  to  the  apex  of  the  orbit.  With  suitable 
retractors  the  orbital  fat  and  ocular  globe  are  pushed  aside.  After  the  exploration 
is  complete,  and  this  must  sometimes  be  carried  to  the  nasal  side  and  the  growth 
removed,  the  osteoplastic  flap  is  replaced,  the  periosteum  stitched  with  fine  catgut 
sutures  and  the  soft  pai'ts  with  silk.  The  question  of  drainage  must  be  decided 
by  the  conditions  remaining  after  operation.  The  usual  full  antiseptic  dressing  is 
applied,  great  care  being  taken  that  the  lids  cover  the  cornea,  especially  if  the  latter 
structure  is  anesthetic. 

Various  complications  have  occurred  after  this  operation;  for  ex- 
ample, outward  limitation  of  the  eye  owing  to  injury  to  the  abducens, 
ptosis,  sinking  of  the  eyeball,  and  infection. 

4€ 


722  OPERATIONS 

Indications. — Domela,  Haab,  and  other  writers  have  classified  the 
indications  for  Kronlein's  operation  as  follows:  Retrobulbar  cj'sts;  tu- 
mors of  the  optic  nerve  and  its  sheath;  neurofibroma  of  orbit  (Parker) ; 
retrobulbar  vascular  growths,  for  example,  cavernous  angioma,  hnrnph- 
angioma,  aneurysms,  and  varicose  dilatations  of  the  orbital  veins; 
deep-seated  foreign  bodies  in  the  orbit  and  exploration  of  the  orbit  in 
doubtful  cases  in  order  to  establish  a  diagnosis.  The  operation  has 
also  been  performed  in  deep  orbital  abscess,  to  open  the  sheath  of  the 
optic  nerve  in  choked  disk,  and  even  for  the  removal  of  subretinal 
effusions  (Miiller).  The  two  last  indications  are  of  doubtful  value; 
certainly  in  choked  disk  a  far  better  operation  is  a  decomjiression- 
trephining. 

Gifford  recommends  as  a  substitute  for  the  Kronlein  operation  a 
definite  resection  of  the  outer  wall  of  the  orbit.  He  makes  a  horizontal 
incision  2H  to  3  inches  long,  beginning  }i  inch  from  the  outer  commis- 
sure, care  being  taken  not  to  open  into  the  conjunctival  sac.  Next, 
the  lips  of  the  wound  should  be  widely  separated,  and  the  periosteum 
pushed  back  from  the  outer  side  of  the  bone.  Following  this,  with 
strong  bone  forceps  the  outer  margin  of  the  orbit  and  as  much  of  the 
outer  wall  as  desired  is  removed.  Finally,  the  periosteum  of  the  orbit 
is  opened,  and  the  operation  terminates  in  the  usual  manner. 

OPERATIONS  FOR  CATARACT 

The  following  methods  constitute  the  most  important  varieties  of 
operation  which  are  practised  for  the  cure  of  cataract: 

Extraction  without  iridectomy,  so-called  simple  extraction;  extrac- 
tion with  iridectomy,  so-called  combined  extraction;  extraction  in  the 
capsule,  with  or  without  iridectomy;  linear  extraction;  the  needle  opera- 
tion, or  discission;  and  the  suction  method.  The  old  operation  of 
reclination,  depressing,  or  couching,  as  it  has  been  variously  called,  by 
which  the  lens  was  forcibly  thrust  down  into  the  vitreous,  is  rarely 
practised  at  the  present  time,  although  some  surgeons  have  suggested 
that  the  operation  is  advisable  in  patients  greatly  enfeebled  by  age  or 
other  infirmities,  if  chronic  conjunctivitis  or  dacryocystitis  fails  to 
yield  to  treatment,  in  lunatics,  imbeciles,  and  others  whose  actions 
oannot  be  controlled,  and  i^articularly  if  one  ey(>  has  been  lost  by  intra- 
oculai-  lieniorrhage. 

1.  Needle  Operation  (Disciss^ion — Operdtion  for  Solution). — By 
this  operation  the  cajisule  of  the  lens  is  opened,  the  aqueous  humor  ad- 
mitted to  the  lens  matter,  and  abs()r])t  ion  thus  promoted.  It  isai)plic- 
able  to  congenital  and  juvenile  cataracts,  and  to  some  ti:iumatic  cata- 
racts, and  is  rarely  erii])loye(l  after  the  fifteenth  year. 

The  instruments  re<iuiit'(l  are  two  cataract  needles  Oance-lieailed  or 
knife-needle,  according  to  the  raiic.\  of  the  oi)erator),  a  stop  .s])eculum. 
and  fixation  force])s.  The  eye  in  this  and  all  operations  of  similar  char- 
acter should  be  i)repared  in  the  inaiiner  described  on  i)age  727. 

After  the  induct  ion  of  general  anesthesia  in  young  children.  t»r  t  he 


fl 


NEEDLE  OPERATION 


723 


use  of  cocain  in  older  subjects,  and  full  dilatation  of  the  pupil,  the 
operation  is  thus  performed: 

The  lids  being  separated  by  the  stop  speculum,  the  surgeon  fixes  the  eye  with 
forceps,  and  enters  the  cataract  needle  through  the  cornea  at  its  outer  margin  or 
at  the  limbus  and  carries  it  across  to  the  center  of  the  pupil,  where  the  point  is 


Fig.  361. — -Bowman's  stop  needle. 


Fig.  362. — Knife- needle. 


turned  to  the  len.s,  and  a  laceration  made  in  the  capsule  bj^  depressing  the  handle  of 
the  instrument  with  a  lever-like  movement.  Two  cuts  are  made  at  right  angles  to 
each  other,  and  the  lens-matter  may  then  be  slightly  broken  up  with  the  point  of 
the  needle.  Care  muat  be  taken  not  to  use  so  much  force  as  to  dislocate  the  lens, 
and  not  to  lacerate  too  freely  in  the  first  operation,  lest  the  lens  substance,  swelling 
up  from  contact  with  the  aqueous  humor,  should  produce  injurious  pressure  on  the 
iris  and  ciliary  body.  The  operation  usually  has  to  be  repeated  at  intervals,  the 
second  operation  being  performed  after  the  swollen  lens  matter  caused  by  the  first 
incision  has  disappeared  by  absorption  and  the  eye  has  become  perfectly  quiet. 


Fig.  363. — Discission  with  two  needles. 

At  the  second  operation  the  needle  may  be  used  more  freely,  or  two  needles  may 
be  used  in  the  manner  shown  in  Fig.  363.  The  points  enter  the  lens  substance  and 
the  handles  are  approximated,  thus  making  a  decided  separation  in  the  remaining 
opaque  matter.  In  order  to  prevent  too  deep  entrance  of  the  needle  it  is  sometimes 
constructed  with  a  shoulder  (stop  needle;  see  Fig.  361).  In  place  of  this  procedure 
Ziegler's  operation  (see  page  698)  may  be  utilized. 

Instead  of  repeating  the  needlings,  the  first  discission  may  be  very  free,  with  the 
understanding  that  in  ajew  days  it  is  to  be  followed  by  a  linear  extraction  and  a  few 
weeks  later  by  division  of  the  capsule  (C.  F.  Clark).  This  procedure  obviates  the 
delay  often  tedious,  in  obtaining  absorption  of  the  lens  by  successive  discission. 


724 


OPERATIONS 


After-treatment. — The  conjunctival  sac  should  be  irrigated  with 
boric  acid  or  physiologic  salt  solution,  atropin  freely  instilled,  and 
pupillary  dilatation  maintained  duing  the  entire  treatment.  Both 
eyes  should  be  lightly  bandaged. 

Decided  reaction,  with  hyperemia  of  the  iris,  pain,  and  ciliary 
congestion,  indicates  a  more  frequent  use  of  atropin,  dionin.  and  iced 
compresses.  Great  swelling  of  the  lens  matter,  in  addition  to  the 
sj'mptoms  of  iritis,  may  give  rise  to  a  glaucomatous  state.  In  these 
circumstances  the  lens  matter  which  has  escaped  into  the  anterior 
chamber  must  be  evacuated  by  a  linear  exlrnciion  or,  what  is  practically 
the  same  thing,  by  a  free  paracentesis  of  the  cornea.  The  suction 
method  may  also  be  emploj'ed  in  these  circumstances  but  irrigation  of 
the  anterior  chamber  is  more  satisfactory. 

For  the  removal  of  the  lens  in  high  myopia  (see  page  142)  needling  is 
employed.  According  to  W.  E.  Lambert,  the  Fukala  method,  that  is, 
needling  the  lens  followed  by  a  linear  extraction,  yields  the  best  results 
in  young  subjects.  If  the  patient  is  fifty  or  more  years  of  age,  and  the 
lens  is  more  or  less  cataractous,  Lambert  advises  a  preliminary  iridec- 
tomy with  subsequent  extraction  of  the  lens  in  the  usual  manner. 

2.  The  Suction  Method. — This  operation  is  specially  adapted  for 
completely  soft  or  fluid  cataracts,  and  is  also  used,  as  has  been  stated, 
to  remove  lens  matter  which  has  been  broken  up  by  discission  or  by 
traumatism.     It  is  performed  as  follows: 

The  pupil  being  dilated  with  atropin,  the  anterior  capsule  of  the  lens  is  freely 
lacerated  with  two  needles.  A  small  wound  is  made  with  a  keratome  passed  ob- 
liquely through  the  cornea  between  its  center  and  periphery.  Through  this  open- 
ing and  into  the  lens  matter  the  "suction  curet"  is  passed.  This  consists  of  a  curet 
roofed  in  to  within  2  mm.  of  its  extremity,  with  a  handle  and  a  piece  of  India- 
rubber  tubing  furnished  with  a  mouth-piece,  which  the  operator  applies  to  his  lips 
and  gently  sucks  out  the  lens  matter  into  the  syringe.     This  is  Teale's  method. 

The  same  may  be  accomplished  by  using  the  syringe  of  Bowman,  in  which  a 
sliding  piston  is  worked  by  the  hand.  The  point  of  the  syringe  must  not  penetrate 
too  deeply,  must  be  behind  the  lens  matter  which  is  to  be  removed,  and  must  not 
be  pushed  back  of  the  iris. 

The  after-treatment  consists  of  rest,  bandage,  and  the  local  use 
of  atropin. 

3.  Linear  Extraction. — This  operation  is  designeti  lor  tlic  ninoval 
of  soft  cataracts  in  jx'isons  under  tiie  age  of  35  (or  even  older  [W  ildcrj), 
and  is  employed  to  remove  lens  matter  after  discission.  Any  lens  the 
substance  of  which  is  liquid  enough  to  pass  through  a  small  corneal 
wound  may  be  removed  by  this  method.  For  traumatic  cataract 
in  patients  not  above  40  years  of  age  it  should  be  tlie  ojx'ration  of 
choice.  A  ])r('Hiiiiiiai>'  discission  is  of  advantage.  Wilder  recom- 
mends the  (jjx'ration,  according  to  a  special  technic  (^.Vgnew's  method), 
in  membranous  cataracts. 

The  following  instruments  are  necessary:  .\  keratome  or  lance- 
shaped  knife,  fixation  forceps,  cystotome,  curet,  and  stop  speculum. 
The  (tperation  is  as  follows: 


EXTRACTION  OF  HARD  CATARACT 


725 


The  surgeon  fixes  the  eye  with  forceps,  after  the  introduction  of  the  stop  specu- 
lum, wide  dilatation  of  the  pupil  having  previously  been  obtained,  introduces  the 
keratome  about  1  mm.  within  the  margin  of  the  cornea,  or  just  at  the  anterior 
edge  of  the  corneoscleral  margin  (Wilder),  and  makes  a  wound  5  mm.  wide.  The 
instrument  is  now  carefully  withdrawn,  with  a  slight  lateral  motion  to  make  the 
wound  a  little  larger  if  necessary,  and  a  sharp  cystotome  is  introduced  and  the 
capsule  of  the  lens  is  freely  lacerated.  The  soft  lens  matter  is  now  caused  to 
extrude  by  counterpressure  on  the  cornea  with  a  metal  spud,  the  outer  lip  of  the 
corneal  wound  at  the  same  time  being  depressed  with  a  curet.  This  is  a  simple 
linear  extraction. 

The  same  manipulations  msiy  be  performed,  assisted  b}"  an  iridectomy  after  the 
corneal  section,  a  small  segment  of  the  iris  being  withdrawn  either  with  hook  or 
forceps  and  excised.  Instead  of  using  the  cystotome  to  open  the  capsule  of  the 
lens,  some  operators  do  this  with  the  keratome  after  making  the  incision  in  the 
cornea  by  causing  the  instrument  to  dip  directlj-  into  the  lens,  from  which  it  is 
next  slightly  withdrawn  and  as  it  is  pressed  gently  backward  the  wound  gapes 
and  through  it  and  over  the  surface  of  the  keratome  the  soft  lens  matter  exudes. 
Any  remnants  of  lens  material  can  readQy  be  removed  by  irrigating  the  anterior 
chamber  with  physiologic  salt  solution. 

The  after-treatment  consists  of  bandage,  atropin,  and  rest  in  bed 
until  the  eye  is  quiet. 


Fig.  364. 


Fig.  366. 


Fig.  367. 


Fig.  368. 


Fig.  364. — Flap  extraction. 

Fig.  365. — Modified  flap  extraction  (Knapp's  section). 

Fig.  366. — Modified  peripheral  Hnear  incision. 

Fig.  367. — Short  3-mm.  flap  -wath  iridectomy. 

Fig.  368. — Corneal  incision  below. 


4.  Extraction  of  Hard  Cataract. — It  would  be  impracticable  to 
indicate  the  numerous  modifications  which  have  been  employed  in  this 
operation,  than  which,  as  the  late  Dr.  Noyes  has  said,  no  surgical  pro- 
cedure has  been  more  carefully  studied  and  elaborated  in  every  detail. 
Hence  only  a  few  well-recognized  methods  will  be  described. 

(a)  Extraction  without  iridectomy,  often  called  simple  extraction. 
The  author  is  accustomed,  following  the  directions  of  the  late  Dr.  H. 
Knapp,  to  proceed  as  follows:  The  corneal  section  for  full-sized  cata- 
racts comprises  exactly  the  upper  half  of  the  cornea;  for  smaller,  Mor- 
gagnian and  soft  cataracts,  somewhat  less.  A  perfect  section  passes  in 
its  whole  extent  exactly  through  the  transparent  margin  of  the  cornea, 
the  knife  (see  Fig.  373)   remaining  in  the  same  plane  throughout, 


726 


OPERATIONS 


particular  care  being  taken  that  in  completing  the  section  the  blade  of 
the  knife  is  not  turned  forward  nor  backward.  In  many  cases  a  small 
central  conjunctival  flap  is  formed,  which  is  an  advantage.  (For 
steps  of  ojx'ration  see  pages  729-733.) 

(h)  Extraction  with  iridectomy,  often  called  combined  extraction. 
The  peripheral  linear  extraction  of  von  Graefe,  by  means  of  which  the 
extreme  periphery  of  the  anterior  chamber  was  opened  by  an  incision 
10  mm.  long,  through  the  sclera,  1  mm.  external  to  the  margin  of  the 
cornea  and  2  mm.  below  the  tangent  of  its  summit,  has  been  abandoned 
bj'  almost  all  operators  owing  to  its  dangens — hemorrhage  from  the  con- 
junctiva, loss  of  vitreous  favored  by  the  peripheral  position  of  the 
wound  and  cyclitis,  and  consequently  danger  of  sympathetic  involve- 
ment of  tiie  other  eye — and  in  its  place  one  or  other  of  the  various  so- 
called  short-flap  operations  is  performed. 

A  useful  method  is  the  following:  A  Graefe  cataract  knife  is  entered 
exactly  at  the  corneoscleral  junction  at  the  outer  extremity  of  a  hori- 
zontal line  which  would  pass  3  or  4  mm.,  according  to  the  size  of  the 
cataract,  below  the  summit  of  the  cornea.  Counterpunctiire  is  made 
at  a  similar  point  directly  opposite,  and  a  flap  is  cut  which  embraces 
one-fourth  or  one-third  of  the  cornea.  A  small  conjunctival  flaj)  may 
be  made  or  not.  Iridectomy  is  performed.  (For  steps  of  operation, 
see  pages  729-733.) 

With  the  various  corneal  incisions  which  have  from  time  to  time 
been  practised  for  the  removal  of  cataract  the  author  has  no  exp(>rience. 
Liebreich  made  an  incision  in  the  form  of  a  curved  section  through  the 
lower  portion  of  the  cornea,  puncture  and  counterpuncture  being 
effected  in  the  sclera,  while  Lebrun  caused  the  corneal  flap  to  occupy 
the  upper  portion  of  the  cornea  and  to  be  3  mm.  high,  inincture  and 
counterpuncture  being  made  2  mm.  below  the  extremities  of  the  trans- 
verse diameter  of  the  cornea.  In  these  operations  iridectomy  was 
usually  omitted. 

(c)  Extraction  without  capsulotomy  is  performeti  by  many  sur- 
geons— that  is  to  say,  the  lens  is  delivered  in  its  capsule.  The  opera- 
tion was  formerly  chiefly  employed  to  remove  overripe  cataracts  and 
cataracts  comjijlicating  high  myopia  with  vitreous  changes.  Pa)..en- 
stecher  in  these  circumstances  exjielled  the  lens  after  an  incision  of 
about  one-third  of  the  corneal  circumference  and  an  ui)ward  iridec- 
tomy. The  expulsion  was  accomplished  either  by  i)ressure  or  witii  the 
aid  of  a  spoon  or  loop.  The  chief  danger  of  the  operation  is  the  risk 
of  extensive  loss  of  vitreous.  The  visual  results  are  very  good  in  suc- 
cessful cases. 

Home  ophthalmic  surgeons  of  great  exix'iieiice  in  India  and  in  this 
country  beli(;ve  that  extraction  in  the  cajjsule  should  be  the  ojx'ration 
of  election.     (For  Colonel  Smith's  Method,  see  page  735.) 

Preparation  of  the  Patient  and  the  Eye.-  This  should  include  a 
thorough  cXMiiiiiial  ion  of  tlic  ]);iti('iil,  and  the  rcni()\al  of  the  condi- 
tions alrcadx'  nanicil  (sec  jja^c  W'A).  which  coiil  laiiuhcatc  the  opera- 
tion. 


EXTRACTION  OF  HARD  CATARACT  727 

For  some  days  previous  to  the  operation,  as  H.  Knapp  insisted,  the 
eye  should  be  protected  from  anything  which  may  produce  congestion, 
and  the  patient  should  remain  in  the  hospital,  perfectly  resting  his  eye 
and  body,  and  frequently  washing  his  face  and  the  surfaces  and  mar- 
gins of  the  eyelids  with  soap  and  water.  This  simple  regimen  will  fre- 
quently change  a  congested  and  irritated  conjunctiva  into  a  pale  and 
shining  membrane.  If  there  is  an}^  abnormal  conjunctival  discharge 
the  instillation  of  a  solution  of  argyrol  (25  per  cent.)  is  recommended  by 
some  surgeons,  who  also  employ  this  drug  in  subsequent  dressings  of 
the  operated  e3^e  (Callan).  Bacteriologic  examination  should  always 
be  made,  and  if  pathogenic  organisms  are  present  the  operation  should 
be  postponed  until  they  have  been  made  to  disappear  by  suitable  treat- 
ment. Axenfeld  recommends  an  injection  of  antipneumococcic  serum 
prior  to  the  performance  of  an  operation  in  the  presence  of  conjunctival 
pneumococci.  During  these  days  scrupulous  attention  should  be  given 
to  the  nasopharynx,  the  tonsils,  teeth  and  alimentary  canal.  The 
urine  should  be  carefully  examined  and  the  blood  pressure  tested. 
The  author,  following  a  suggestion  of  J.  A.  Lippincott  is  accustomed 
to  spray  the  nasopharynx  three  times  daily  with  a  solution  of  per- 
manganate of  potassium  (1:  5000),  with  gratifying  results.  Dr.  J. 
A.  White  recommends  that  the  conjunctival  sac  shall  be  filled  with 
bichlorid-vaselin  (1 :  3000)  on  the  night  prior  to  the  operation,  where 
it  remains  until  the  next  day. 

The  preparation  of  the  skin  of  the  region  of  operation,  and  particu- 
larly the  ciliary  margins,  has  been  described  on  page  654.  These 
preparations  should  be  made  at  least  two  hours  before  the  operation, 
and  the  eyes  should  be  covered  with  squares  of  lint  soaked  in  a  solu- 
tion of  bichlorid  of  mercury  (1  :5000),  held  in  place  with  a  gauze 
roller.  Just  preceding  the  operation,  the  preparatory  bandage  having 
been  removed,  the  ciliary  margins  may  again  be  washed  with  soap  and 
water,  followed  by  bichlorid  of  mercurj^  (1:  5000),  with  the  same  pre- 
cautions previously  described  (see  page  654).  Next,  the  conjunctival 
culdesac  should  be  flushed  with  a  tepid  solution  of  boric  acid  applied 
with  some  force,  or  with  a  sterile  physiologic  salt  solution.  During 
these  irrigations  pressure  should  be  made  over  the  lacrimal  sac  in  order 
to  be  sure  that  no  deleterious  secretion  is  contained  within  it.  The 
canaliculi  and  lacrimal  canal  may  be  irrigated  with  a  boric  acid  or  saline 
solution  introduced  by  means  of  an  Anel  syringe.  The  lids  are  next 
everted,  the  tarsal  conjunctiva  and  the  region  of  the  inner  canthus 
wiped  with  a  pledget  of  cotton  moistened  in  the  boric  acid  solution. 
The  cornea  should  be  anesthetized  with  three  instillations  of  a  sterile 
4  per  cent,  solution  of  cocain,  applied  at  intervals  of  five  minutes,  and 
the  eye  carefully  closed  and  covered  with  the  antiseptic  pad  after 
each  instillation.  In  place  of  cocain  some  surgeons  prefer  holocain 
in  2  per  cent,  solution  or  a  mixture  of  holocain  and  cocain.  Just 
before  the  knife  is  entered  the  surface  of  the  cornea  should  be  care- 
fully wiped  with  a  pledget  of  cotton  soaked  in  boric  acid  solution. 
This  same  method  of  preparing  an  eye  should  be  practised  not  only  in 


728 


OPERATIONS 


cataract  extraction  and  ili.scLssion,  but  also  jjrior  to  all  operations  re- 
quiring corneal  incision — for  example,  iridectomj',  iridotomy,  etc. 
"With  injection  of  plu'siologic  salt  solution  prior  to  extraction  to  deepen 
an  abnornmlly  shallow  antei-ior  chamlu'r  the  author  has  had  no  exjx'ri- 
ence.  He  has  not  deemed  it  wise  to  fiusli  the  conjunctival  sac  vigor- 
ously with  strong  solutions  (1:  2000  or  3000)  of  bichlorid  of  mercury, 
but  this  practice  is  commended  by  surgeons  of  great 
experience,  for  example,  Col.  Henrj'  Smith.  Placing  a 
preparatory  dressing  over  the  eyes  during  the  night  i)re- 
ceding  the  operation  the  author  is  satisfied  is  an  unwise 
])ro('e<lui('. 

Position  of  the  Patient. — The  patient  during  the 
operation  should  lie,  according  to  the  custom  of  the 
operator,  u])on  an  operating  chair  or  table.  If.  as  is 
sometimes  advisal)l(\  the  oi)eration  is  performed  while 


Fici.  370.— 
Metal  spoon. 


Fig.  371.— 
Wire  loop. 


Fig.  372.— 
Cystitome. 


Fig.  373.— 
Cataract  knife. 


Fig.     309.— Li<i- 
t'levator. 


Fig.  ;i74. 


ipsillr    Ii'li 


the  i)atieiit  reclines  in  l)ed,  the  head  shduld  icsl  on  a  moderately 
hard  cushion  or  pillow,  covered  with  a  sterile  sheet,  another  pillow 
at  the  same  time  sup])orting  the  shoulders,  so  that  the  jjosition  is  as 
little  strained  as  jxissible.  In  all  circumstances  the  face  must  be 
turned  so  that  uniform  d;i.\  light  falls  upon  it.  or  the  are.-i  of  oper;ition 
should  be  illuminated  with  ;i  suitMble  electric  l.inip,  the  imxlel  of 
Ziegh'f  iieilig  nidsl   s;it  isl:icl  orw 

Instruments,  Solutions,  and  Dressings.  The  inst lumeiils  retiuin-d 
are  th(^  following:  \  stoj)  speculum,  a  lid-elevator,  a  large  strabismus 
hook,  a  s]);itul;i,  ;i  wire  loop,  a  s|)(i(»n.  mu  oli\'e-tip])ed  probe.  :i  curet,  a 


EXTKACTION  OF  HARD  CATARACT  729 

cystitome,  capsule  forceps,  a  pair  of  scissors,  iris  forceps,  iris  scissors, 
and  the  cataract  knife. 

The  following  lotions  and  dressings  should  be  at  hand:  Atropin 
drops,  4  grains  (0.26  gm.)  to  the  ounce  (30  c.c);  eserin  drops,  3^^  grain 
(0.0324  gm.)  to  the  ounce  (30  c.c);  cocain  solution  (4  per  cent.);  satu- 
rated solution  of  boric  acid;  two  solutions  of  bichlorid  of  mercury 
(1 :  5000  and  10,000),  and  boiled  distilled  water  containing  0.5  per  cent, 
of  chlorid  of  sodium.  Suitable  bulb  syringes  and  an  irrigating  appa- 
ratus, for  example,  Lippincott's,  or  the  one  described  on  page  445, 
should  be  ready. 

For  the  purpose  of  dressings  the  following  may  be  needed :  Several 
rollers,  2  inches  wide  and  5  yards  long,  made  of  sterilized  gauze,  and 
sterilized  oval  pads  of  lint  and  absorbent  cotton.  A  useful  bandage  is 
composed  of  a  broad  band  of  knitted  material  which  is  tied  with  four 
tapes,  which  pass  above  and  below  each  ear. 

Everything  being  in  readiness,  the  operation  may  be  performed- as 
follows : 

The  surgeon,  if  he  is  ambidextrous,  may  stand  behind  the  patient,  no  matter 
which  eye  is  to  be  operated  upon;  if  he  is  not,  he  should  take  this  position  for  the 
right  eye  only,  standing  at  the  patient's  side  and  in  front  for  an  operation  on  the  left 
eye.  Again,  if  the  surgeon  is  ambidextrous,  he  may  stand  in  front  and  at  the 
patient's  right  side  for  an  operation  upon  the  right  eye,  and  at  the  patient's  left  side 
and  in  front  for  an  operation  on  the  left  eye. 

The  speculum  having  been  inserted,  the  surgeon  steadies  the  eyeball  and  draws 
it  downward  with  the  fixation  forceps  (it  is  supposed  that  the  section  is  being  made 
upward)  by  taking  firm  hold  of  a  fold  of  conjunctiva  below  the  inferior  border  of  the 
cornea  (some  surgeons  prefer  fixation  at  the  inner  side,  over  the  internal  rectus 
tendon),  enters  a  Graefe  cataract  knife  exactly  at  the  corneoscleral  junction,  as 
before  described,  at  the  outer  extremity  of  a  horizontal  line  which  would  pass  3  or 
4  mm.,  according  to  the  size  of  the  cataract,  below  the  summit  of  the  cornea,  passes 
across  the  anterior  chamber  to  a  corresponding  point  upon  the  opposite  side,  and 
makes  the  counterpuncture.  The  knife  is  pushed  steadily  onward  as  far  as  pos- 
sible, with  an  upward  tendency,  and  the  incision  is  completed  by  a  free  cutting,  not 
a  sawing  or  dragging  movement,  keeping  the  knife  in  the  same  plane  throughout, 
and  not  turning  its  edge  at  the  completion  of  the  section  either  forward  or  back- 
ward. This  maneuver  will  create  a  small  conjunctival  flap.  If  this  is  not  desired, 
when  the  summit  of  the  cornea  is  reached  the  knife  must  be  turned  a  little  forward 
before  the  completion  of  the  flap.  It  is  the  practice  of  some  surgeons  to  remove  the 
speculum  as  soon  as  the  section  is  completed;  other  operators  prefer  not  to  use  a 
speculum,  but  to  separate  the  lids  with  their  fingers  or  with  a  lid-elevator  or  a 
Smith's  or  Fisher's  hook  held  by  an  assistant.  This  completes  the  first  stage 
(Fig.  375). 

In  the  second  stage,  or  the  stage  of  iridectomy,  the  fixation  forceps  are  intrusted 
to  the  assistant  (trained  to  hand  the  instruments  in  their  proper  order),  who  gently 
draws  the  eyeball  downward,  while  the  operator  takes  in  his  left  hand  the  iris 
forceps  and  in  his  right  the  iris  scissors.  If  the  iris  is  already  protruding  in  the 
wound,  a  small  portion  of  it  may  be  seized  and  snipped  off  with  a  single  cut  close  to 
the  border  of  the  cornea.  If  not,  the  blades  of  the  instrument  must  be  introduced 
in  the  manner  described  under  Iridectomy,  and  the  pupillary  border  of  the  iris 
seized,  the  tissue  drawn  out  and  toward  the  cornea,  and  cut  off  close  to  the  cornea. 
It  is  not  necessary  to  make  a  large  coloboma.  If  the  patient  is  to  be  trusted,  it  is 
not  necessary  that  the  assistant  shall  draw  the  eyeball  downward  while  iridectomy 
is  being  performed.     The  patient  may  simply  be  directed  to  look  downward  while 


730 


OPERATIONS 


the  surgeon  proceeds  to  remove  a  small  portion  of  the  iris  in  the  manner  already 
described.  The  pillars  of  the  coloboma  should  now  be  carefully  smoothed  out 
with  a  deUcate  spatula.     This  completes  the  second  sta{)e  (see  Fig.  332). 

In  the  third  stage,  or  the  stage  of  capsulotomy,  the  operator  takes  in  one  hand 
the  fixation  forceps  and  gently  steadies  the  eyeball,  while  with  the  other  he  intro- 
duces the  cystitome,  held  flatwise  during  its  insertion,  passes  it  to  the  bottom  of  the 
coloboma,  and  then  turns  its  cutting-edge  toward  the  capsule.  From  tliis  point 
a  vertical  incision  is  traced  until  the  upper  portion  of  the  coloboma  is  rciiched, 
where  a  transverse  cut  is  made.  Great  care  should  be  taken  to  cut,  and  not  to  tear, 
and  the  whole  maneuver  should  be  accomplished  without  undue  pressure  lest  the 
lens  be  dislocated.  Other  methods  of  opening  the  capsule  are  the  following;:  Two 
cuts  inclined  to  each  other  are  made  like  the  limbs  of  the  inverted  letter  Vj  together 
with  a  transverse  cut  at  the  periphery;  or,  as  was  recommended  by  H.  Knai)p,  the 
capsule  may  be  opened  in  its  extreme  periphery,  with  the  understanding  that  later 
on  the  necessity  for  the  operation  for  after-cataract  will  arise.  In  withdrawing  the 
cystitome  the  operator  should  again  turn  it  flatwise,  and  be  careful  not  to  drag  any 
tags  of  capsule  into  the  wound.  The  cystitome  (Fig.  372)  often  employed  is  not  a 
satisfactory  instrument;  one  with  a  small  oval  knife-like  blade  such  as  Zieglcr  has 
devised,  is  a  much  better  instrument  in  that  it  easily  cuts  the  capsule. 


Fig.  375, — The  incision  in  cataract  extraction.  Puncture  and  cmintorpiincture 
have  been  made.  The  section  will  pass  in  its  whole  extent  exactly  through  the  trans- 
parent margin  of  the  cornea,  the  knife  remaining  in  the  same  plane  throughout. 

Manj'  surgeons  disregard  the  cystiluiiio  luul  open  the  c.-ipsule  with  cupsidc 
forceps;  after  introduction,  the  blades  arc  slightly  expanded  and  the  centinl  portion 
of  the  capsule  seized  in  tiioir  grasp  and  removed.  This  procedure  usually  obviates 
the  necessity  of  a  .secondary  operation.     This  completes  the  third  stage. 

In  the  fourth  stage,  or  that  of  delivery  of  the  cataract,  the  operator  draws  the  eye 
slightly  downward,  or,  if  he  has  a  docile  patient,  causes  him  to  look  ilownward, 
while  the  assistant  rai.ses  the  speculum  so  that  its  blades  shall  not  press  upon  the 
eyeball  and  yet  shall  hold  the  lids  away  from  the  eye  or  lifts  the  upper  lid  with  a 
Smith's  hook  or  with  an  elevator,  at  the  same  time  drawing  away,  with  his  thumb, 
the  lower  lid  from  contact  with  the  globe.  The  back  of  a  curet  or  the  convex 
surface  of  the  metal  spoon  is  now  laid  against  the  inferior  portion  of  the  comen,  and 
firm  but  at  the  same  lime  gentle  pressure  is  made,  causing  the  upper  margin  of  the 
lens  to  appear  in  the  wound.  The  pressure  is  e.\ercised  with  an  ujjwaiil  motion  to 
coax  out  tlie  cataract,  but  is  relaxed  as  soon  as  the  major  portion  1ms  been  expt'lled, 
in  order  that  no  undue  tension  be  put  upon  the  zomila.  As  the  cataract  slips 
through  the  wound  the  spoon  is  mad(>  to  follow  it,  catch  it,  and  lift  it  out  witl>  a 
little  Hweejjing  motion  which  miiy  at  the  s:ime  time  riMiiove  any  sni.'ill  fragments  of 


EXTRACTION  OF  HARD  CATARACT  731 

the  cortex  which  have  broken  off  and  lie  at  the  margins  of  the  incision.  The 
speculum  or  lid-elevator  is  then  removed.  This  completes  the  fourth  stage  (Fig. 
376). 

In  the  fifth  stage,  or  that  which  is  now  called  the  "toilet  of  the  wound,"  after  the 
eye  has  been  allowed  to  remain  closed  for  a  few  moments  the  operator  cautiously 
inspects  the  wound,  after  raising  the  upper  lid  with  his  fingers,  or  preferably  with  a 
Smith  hook,  while  the  patient  looks  downward.  In  this  inspection  he  should  ascer- 
tain whether  the  pupil  is  clear  or  whether  any  cortical  remnants  are  present  or  tags 
of  capsule  lie  between  the  lips  of  the  incision.  If  cortical  matter  remains,  it  should 
be  removed  as  follows:  The  eye  being  turned  downward,  the  operator  makes  a 
gentle  rubbing  movement  in  an  upward  direction  on  the  cornea  with  the  convex 
surface  of  a  horn  spoon,  great  care  being  taken  not  to  press  too  hard  lest  vitreous 
escape.  By  rubbing  gently  in  a  circular  manner  the  cortical  particles  will  gather  in 
the  upper  part  of  the  wound,  and  then,  while  the  slight  pressure  continues,  the  lips 
of  the  wound  may  be  gently  separated  with  the  metal  spatula  and  the  expulsion  of 
the  cortical  remnants  effected.  Blood-clot,  the  result  of  hemorrhage  from  the  iris, 
may  be  expelled  in  like  manner.  While  these  manipulations  are  being  made,  the 
author  is  accustomed  to  flood  the  surface  of  the  eye  and  lips  of  the  wound  with  a 
physiologic  salt  solution.     After  they  are  completed,  a  final  inspection  is  made,  and 


Fig.  376. — The  delivery  of  the  lens;  the  lens  is  presenting  in  the  wound  (capsulotomy 

has  been  performed). 

in  order  to  be  sure  that  no  tag  of  capsule  remains  in  the  wound,  or  that  no  portion  of 
the  conjunctival  flap  has  been  caught  between  its  lips,  the  olive-pointed  probe  is 
gently  passed  from  one  end  of  the  incision  to  the  other. 

Some  surgeons  advocate  irrigation  of  the  anterior  chamber,  which,  as  has  already 
been  stated,  is  used  also  in  the  operation  of  unripe  cataract.  In  this  maneuver  the 
tip  of  a  specially  devised  syringe  is  introduced  between  the  lips  of  the  wound,  and 
the  irrigating  liquid  injected,  which  causes  blood-clot  or  cortical  matter  to  be 
washed  out.  If  irrigation  is  employed,  two  cautions  are  necessary :  (a)  No  strong 
antiseptic  solution  should  be  used,  certainly  never  bichlorid  of  mercury,  which  is 
liable  to  produce  indelible  staining  of  the  cornea.  The  irrigating  fluid  should  be 
boiled  distilled  water  containing  0.5  per  cent,  of  the  chlorid  of  sodium,  (b)  In 
passing  the  liquid  from  the  syringe  into  the  anterior  chamber,  the  direction  of  the 
flow  should  be  over  the  wound  from  within  outward,  and  not  the  reverse,  lest 
particles  of  blood  and  cortex  be  driven  inward. 

A  general  inspection  of  the  conjunctival-sac  may  now  be  made;  sometimes  a 
little  blood-clot  or  a  cilium  may  be  present.  In  wiping  away  any  clots,  delicate 
pieces  of  sterihzed  gauze  are  very  suitable,  or  the  clots  may  be  picked  up  with  the 
iris  forceps.  If  all  these  manipulations  have  been  successfully  performed,  the  con- 
junctival culdesac  will  be  free  from  foreign  matters,  the  edges  of  the  wound  nicely 
coapted,  the  pillars  of  the  coloboma  as  straight  as  possible,  and  the  angles  not 


732  OPERATIONS 

caught  in  the  margins  of  the  wound,  the  pupil  black,  and  the  patient  readily  able 
to  count  fingers.     ThLs  completes  the  fifth  stage. 

If  the  operator  intends  to  perform  extraction  without  iridectomy,  the 
following  additional  directions  will  be  found  useful.  As  the  author  is 
accustomed  to  perform  the  operation  according  to  the  late  Dr.  H. 
Knapp's  rules,  the  advice  of  this  surgeon  is  quoted: 

After  performing  the  section  according  to  the  method  already  given  (see  page 
729,  also  Fig.  375),  the  expulsion  of  the  lens  is  effected  by  pressing  the  lower  part  of 
the  cornea  with  a  Daviel  spoon  directly  toward  the  center  of  the  globe.  When  the 
lens  presents  in  the  gaping  section,  its  exit  is  aided  by  slight  strokes  with  the  spoon 
on  the  outer  surface  of  the  cornea.  If  the  sphincter  proves  to  be  rigid,  it  may  be 
drawn  backward  with  a  wire  loop  or  with  a  special  iris  retractor,  and  usually  it  is 
safer  to  remove  both  fixation  forceps  and  speculum  immediatelj-  after  the  corneal 
section  and  during  the  process  of  expelling  the  len.s,  or  the  speculum  may  be  raised 
in  the  manner  already  described.  If  desirable,  the  upper  lid  may  be  elevated  in 
these  circumstances  with  a  large  strabismus  hook  or  witli  a  lid-elevator.  The 
pupillary  space  should  be  cleared  by  pressing  on  the  cornea  with  the  edge  of  the 
lower  lid— care  being  taken  that  it  does  not  come  in  contact  with  the  lips  of  the 
wound — or,  better,  with  the  convex  surface  of  a  polished  spoon.  The  cortical 
remnants  are  wiped  away  with  a  probe-pointed  curet.  During  this  operation  the 
lips  of  the  wound  may  be  flooded  with  the  boric  acid  or  sterilized  salt  solution 
(Knapp  used  a  1  :  10.000  solution  of  corrosive  sublimate). 

The  concluding  steps  of  the  operation  are  described  in  Knapp's  own  words: 
"The  conjunctival  flap  is  smoothed  out  by  introducing  the  end  of  a  polished 
grooved  spatula,  previously  sterilized,  into  the  anterior  chamber,  and  passing  it 
through  the  wound  from  one  end  to  the  other,  stroking  from  within  outward,  in 
order  to  remove  particles  of  lens,  redress  a  curved-in  flap,  and  carefully  adjust  the 
edges  of  the  wound.  This  is,  however,  not  done  before  the  irLs  h.is  spontaneously 
or  artificially  recovered  its  natural  position.  Should  the  corneal  section  be  too 
peripheric,  the  best  thing  is  to  make  a  small  iridectomy  at  once,  for  peripheric 
(Graefe's)  sections  commonly  lead  to  large  and  harmful  prolap.ses.  If  the  iris 
does  not  spontaneously  resume  its  position,  frequently  it  does  so  when  the  lower 
part  of  the  cornea  is  pressed  upon  with  the  edge  of  the  lid.  This  paradoxic  i)he- 
nomenon  may  thus  be  explained :  The  iris  being  pinched  in  the  tightly  closing  wound, 
pressure  on  the  part  of  the  cornea  raises  the  flap  and  disengages  the  iris,  which  then, 
by  its  natural  elasticity  and  contraction  of  the  sphincter  pupillaj,  can  resume  its 
natural  position.  If  this  procedure  fails,  the  iris  should  be  pushed  back  with  a 
spatula  into  the  anterior  chamber.  When  the  peripherj'  of  the  iris  remains  folded 
in  the  sinus  of  the  anterior  chamber,  it  is  smoothed  out  with  the  olive-tii)ped  point 
of  a  probe  introduced  into  the  iris  angle  behind  the  opaque  corneal  margin." 

The  final  stage  of  all  cataract  operations  is  the  application  of  the  dressing. 
Much  difference  of  opinion  exists  upon  this  subject.  Some  operators  simply  clo.se 
the  lids  with  a  strip  of  isingla.ss  plaster,  while  others  place  upon  them  an  elaborate 
bandage. 

The  author  is  accustomed  to  use  the  following  dre.ssing:  .\n  oval  piece  of  soft 
lint  soaked  in  a  solution  of  boric  acid  is  laid  upon  each  closetl  lid,  the  margins  of 
which  have  previou.sly  been  liberally  smeared  with  bichlorid-va.selin  (White's  oint- 
ment, .see  page  727) ;  over  this  is  placed  a  similarly  shaped  piece  of  sterilized  cotton, 
large  enough  to  be  flush  with  the  eyebrow  and  lower  margin  of  the  orbit,  and  is  held 
in  i)lace  with  three  narrow  strips  of  surgeon's  isinghi-ss  plaster,  pa.><setl  from  the 
inf(;rior  edge  of  the  orbit  to  a  point  above  the  brow.  Over  this  a  very  light,  single 
piece  of  knitted  bandage  is  ti<Ml  by  means  of  four  ta|)es  which  pass  above  ami  below 
the  ears.  The  entire  dressing  is  usually  covered  with  the  mask  devisetl  by  J)r. 
Frank  King,  of  New  ^'ork  (Fig.  '-M7).  The  pati<Mit  is  put  to  bed  in  a  comfortable 
position  in  a  slightly  darkened  room,  although  with  the  aid  of  the  nui-sk  tiie  latter 
precaution  is  unneceHsary,  and  tii<'  patient   mav  reni.niu  in  the  open  ward  of  the 


I 


EXTRACTION  OF  HARD  CATARACT 


733 


hospital  or  in  an  ordinary  room  without  danger.  If  the  caruncles  are  tumid,  or  if 
there  has  been  any  suspicious  secretion  from  the  lacrimal  sac,  the  author  is  accus- 
tomed to  fill  the  inner  canthus  with  dry  sterile  iodoform  powder,  which  forms  a 
small  cake  and  prevents  access  of  infection  to  the  wound.  Some  surgeons,  for 
example,  H.  Bruns,  in  hospital  practice,  at  least,  pass  two  or  three  strips  of 
plaster  over  the  closed  lids,  put  on  top  of  this  cotton  which  is  held  in  place  with 
strips  of  gauze  and  collodion  and  over  the  whole  a  wire  cage  is  adjusted.  The 
patient  is  allowed  to  go  home  and  comes  daily  for  observation  and  dressing. 

After-treatment. — For  the  first  few  hours,  the  effects  of  the  cocain 
having  passed  away,  there  are  some  smarting  and  burning,  but  severe 
pain  should  not  occur.  If  at  the  end  of  twenty-four  hours  after  a 
combined  extraction  there  has  been  no  discomfort,  no  headache,  and 
nothing  to  indicate  that  any  anomaly 
in  the  course  of  healing  is  going  on,  the 
dressings  need  not  be  removed;  but  if 
they  have  become  disarranged  or  the 
patient  has  been  uncomfortable,  they 
should  be  taken  off  and  the  lids  in- 
spected. A  little  staining  of  the  strip 
of  lint  is  of  no  consequence,  and  if  the 
eyelids  are  not  swollen  and  there  is  no 
discharge  and  the  delicate  veins  in  the 
skin  of  the  lids  show  no  distention, 
the  eyelids  need  not  be  opened  and 
the  dressing  may  be  reapplied;  or  the 
lower  lid  may  be  gently  drawn  down- 
ward so  as  to  permit  the  escape  of 
tears  which  may  have  accumulated  in 
the  conjunctival  culdesac,  or  to  lib- 
erate the  eyelashes  if  they  have  become  inverted.  At  the  end  of 
forty-eight  or  seventy-two  hours  the  wound  may  be  inspected  by 
candle-light,  a  drop  of  sterile  atropin  solution  instilled,  and  each  suc- 
ceeding day  the  usual  dressing  reapphed ;  at  the  end  of  three  days  the 
dressing  may  be  removed  from  the  unoperated  eye,  and  at  the  end  of  a 
week  or  even  earlier  the  patient  needs  only  a  shade  and  dark  glasses. 
Although  some  operators  do  not  require  cataract  patients  to  go  to  bed 
at  all,  it  seems  to  the  author  that  it  is  safer  to  keep  them  in  bed  for  two 
or  three  days.  The  recumbent  posture  too  long  maintained  may  lead 
to  hypostatic  congestion  of  the  lungs.  Sometimes  elderly  patients 
are  very  uncomfortable  when  confined  to  bed  and  become  slightly 
dehrious;  in  these  circumstances  they  may  be  allowed  to  rest  in  an  easy 
chair.  For  a  few  days  liquid  food,  or  at  least  food  which  does  not 
require  much  chewing,  should  be  given;  after  this  the  ordinary  diet 
suited  to  the  patient  is  permissible. 

Some  surgeons  prefer  the  "open  method"  of  managing  eyes  after 
cataract  extraction — i.  e.,  no  occlusive  dressing  is  applied,  but  the 
eye  is  protected  with  spectacles  made  of  wire-gauze  or  similar  material. 
With  this  procedure  the  author  has  no  experience. 

If  the  operation  has  been  an  extraction  without  iridectomy,  it  is 


Fig.  377.- — Ring's  ocular  mask. 


I 

I 


734  OPERATIONS 

proper  to  inspect  the  eye  at  the  first  dressing,  usually  at  the  end  of 
twenty-four  hours,  in  order  to  ascertain  whether  there  has  been  any 
prolapse  of  the  iris.  Should  this  accident  have  occurred,  the  treatment 
must  be  pursued  according  to  the  directions  given  elsewhere.  If  the 
iris  is  in  place  and  the  pupil  circular,  although  it  is  proper  to  change  the 
dressings  once  in  twenty-four  hours,  it  is  unnecessary'  to  inspect  the  line 
of  incision.  All  that  is  required  is  to  draw  down  the  lower  lid  and  per- 
mit the  escape  of  any  accumulated  tears.  As  soon  as  the  wound  is 
closed,  a  drop  of  a  sterile  atropin  solution  may  be  instilled  and  this 
instillation  repeated  at  subsequent  dressings. 

Accidents. — The  following  accidents  may  occur  during  the  per- 
formance of  a  cataract  extraction : 

1.  The  knife  may  be  introduced  with  the  cutting  edge  turned  in  the 
wrong  direction.  If  this  somewhat  inexcusable  mistake  should  occur, 
the  knife  must  be  withdrawn  and  properly  inserted.  If  this  cannot 
be  done,  owing  to  the  escape  of  the  aqueous,  postponement  of  the 
operation  until  the  anterior  chamber  has  refilled  is  necessary. 

2.  The  conjunctiva  in  the  neighborhood  of  the  counterpuncture 
may  become  distended  with  aqueous  humor.  This  produces  an  eleva- 
tion resembling  a  bleb.  The  section  should  be  completed  as  if  the 
accident  had  not  happened. 

3.  The  iris  may  fall  before  the  knife.  The  incision  should  be  com- 
pleted in  the  ordinary  way.  An  irregular  coloboma  will  result,  which 
maj^  be  remedied  by  seizing  the  jagged  edges  with  the  iris  forceps  and 
trimming  them  with  the  scissors. 

4.  Free  hemorrhage  may  occur  if  a  conjunctival  flap  is  made  or  in 
performing  the  iridectomy.  Under  pressure  the  bleeding  will  some- 
times cease,  and  the  operator  should  then  endeavor  to  get  rid  of  the 
blood  in  the  manner  already  described.  If  success  does  not  follow  the 
maneuver,  the  cystitome  must  be  introduced,  even  though  everything 
is  obscured  by  the  blood,  the  capsule  lacerated,  and  the  lens  expelled. 
During  its  expulsion  sufficient  blood  will  often  come  away  to  clear  the 
pupillary  space. 

5.  The  wound  may  be  too  small.  This  is  a  very  unfortunate  occur- 
rence and  can  be  remedied  by  enlarging  the  incision,  which  is  best 
done  with  a  small  pair  of  probe-pointed  scissors. 

6.  Undue  pressure  of  the  cystitome  may  cause  the  lens  to  be  par- 
tially or  completely  dislocated.  If  the  dislocation  is  partial,  the  eyes 
should  be  closed  and  gentle  pressure  should  be  made  with  a  bandage; 
the  lens  probably  will  right  itself  and  can  be  delivered.  If  the  dis- 
location is  complete  and  the  lens  slips  back  into  the  vitreous,  it  must 
be  removed  by  means  of  the  scoop  or  wire  loop  or  by  pressure  (see  page 
450). 

7.  The  vitreous  may  escape  before  or  after  t  he  expulsion  oi'  the  lens.  | 
If  before  the  expulsion  of  the  lens,  the  operator  should  at  once  remove  | 
the  cataract  with  the  wire  loop,  wiiich  is  gently  inserted  behiml  the 

lens.  At  the  same  time  all  i)ressure  upon  the  e3'e  nnist  bi;  removed.  If 
vitreous  escapes  after  the  lens  has  been  extracted,  the  wouiul  should  be 


EXTRACTION  OF  HARD  CATARACT  735 

cleared  of  protruding  vitreous  as  gently  and  rapidly  as  possible  and  a 
bandage  applied.  The  patient  should  be  required  to  look  upward,  as  a 
downward  position  of  the  eye  favors  the  prolapse  of  the  vitreous. 
Although  escape  of  vitreous  is  an  undesirable  accident,  its  consequences 
are  not  a  ways  serious  and  good  visual  results  may  be  obtained.  If  the 
escape  of  vitreous  has  been  great,  particularly  if  the  vitreous  is  thin 
and  there  is  tendency  for  the  eyeball  to  collapse,  a  tepid  sterile  physio- 
logic salt  solution  should  be  injected  into  the  vitreous  chamber  until 
the  globe  assumes  its  proper  contour,  as  has  been  recommended  by 
J.  A.  Andrews  and  Herman  Knapp. 

8.  Occasionally  the  corneal  flap  is  everted  because  it  has  been 
caught  by  the  margin  of  the  hd,  owing  to  a  sudden  movement  of  the 
patient.  It  must  be  replaced  and  a  bandage  quickly  apphed.  Some- 
times immediately  at  the  conclusion  of  the  section,  or  directly  after  the 
deliver}'  of  the  lens,  especially  in  old  and  feeble  subjects,  there  is  great 
collapse  of  the  cornea,  which,  instead  of  keeping  its  proper  curve,  looks 
like  a  wrinkled  membrane.  In  these  circumstances  the  anterior  cham- 
ber should  be  filled  with  physiologic  salt  solution,  which  will  not  only 
aid  in  making  proper  coaptation  of  the  lips  of  the  wound,  but  will 
prevent  the  sucking  in  of  the  conjunctival  juices  which  might  lead  to 
infection. 

9.  Capsulotomy  may  not  have  been  sufl&cient  and  pressure  upon 
the  inferior  half  of  the  cornea  fails  to  cause  the  lens  to  present.  In 
such  a  case  the  cystitome  must  be  reintroduced  and  the  laceration 
enlarged,  or  if  the  obstruction  is  due  to  the  presence  of  a  tenacious 
center  in  the  capsule,  this  ma}'  be  removed  with  capsule  forceps.  In 
most  circumstances  the  use  of  capsule  forceps  is  preferable  to  the 
employment  of  a  cystitome. 

AVithin  the  last  few  years  Colonel  Henry  Smith's  method  of  extrac- 
tion of  cataract  in  the  capsule  (radical  operation  for  cataract,  according 
to  Vail)  has  attracted  much  attention. 

Smith's  Operation  for  the  Extraction  of  Cataract  {Indian  Method 
of  the  Extraction  of  Cataract  in  the  Capsule). — The  operation  is  per- 
formed as  follows:^ 

After  a  spring  speculum  has  been  inserted,  the  eye  being  fixed  with  special 
forceps,  a  Graefe  knife  is  entered  at  the  corneoscleral  junction  and  counterpuncture 
made  in  the  corneoscleral  junction  of  the  opposite  side,  so  that  the  iucision  when 
completed  shall  include  half  or  nearly  half  of  the  circumference  of  the  cornea.  The 
knife  is  driven  through  to  the  heel,  the  handle  being  lowered  as  it  passes  onward 
and  the  point  elevated.  If  the  manipulation  is  a  proper  one,  after  the  counter- 
puncture  is  made  the  knife  cuts  as  it  goes  through  the  tissues,  and  the  incision  is 
completed  with  one  thrust,  the  incision  ending  in  the  cornea  in  such  a  manner  that 
the  edges  of  the  corneal  woimd  are  cut  as  nearly  as  possible  at  right  angles  to  the 
surface.  An  iridectomy  may  or  may  not  be  done,  but  it  is  advisable,  for  the  begin- 
ner at  least,  to  make  this  part  of  the  operative  procedure. 

The  speculum  is  next  removed,  and  the  eyelid  and  brow  are  held  a,wa,y  from  the 
eye  by  means  of  a  large  blunt  hook  and  the  assistant's  fingers  (Fig.  378).  The 
patient  is  required  to  look  steadily  upward.     In  the  case  of  an  immature  lens  or  of  a 

1  This  description,  condensed  and  slightly  modified,  is  taken  from  the  late  Dr. 
D.  W.  Greene's  quotation  of  Colonel  Smith's  own  account  of  his  operation. 


736 


OPERATIONS 


hard  cataract  the  operator  next  presses  back  with  the  point  of  a  strabismus  hook 
toward  the  optic  nerve,  the  point  of  the  hook  being  placed  over  the  lower  third  of 
the  cornea.  This  pressure  must  be  steady,  and  the  point  of  the  hook  should  not  be 
removed  until  the  upper  edge  of  the  lens  tilts  forward.  The  moment  the  lens  is 
seen  to  be  dislocated,  the  pressure  through  the  point  of  the  hook  is  gradually 
turned  more  and  more  toward  the  wound,  pres.sure  during  all  of  this  time  being 
maintained,  so  as  to  keep  the  lens  up  to  the  sclerotic  margin,  the  pressure  with  the 
hook  becoming  gradually  lighter  and  lighter  and  the  hook  gradually  .sliding  under 
the  lens  until  the  cornea  is  folded  beneath  it.  At  this  stage  the  lens  is  delivered 
(Fig.  379). 


Fig.  378. — Smith's  operation  for  cat- 
aract: Spectator's  view,  while  the  lids  are 
beinK  held  by  the  assistant  and  the  hook 
for  expelling  the  lens  is  applied.  Notice 
the  gable-like  space  under  the  upper  lid 
above  the  eyeball.  The  operator  may  look 
obliquely  under  the  iii>pi'r  lid  in  this  fii'lil 
and  get  a  good  exposure  of  the  entire  upper 
culdcsac.  The  assistant  can  shift  this  ex- 
posure to  the  right  or  left  to  enable  the 
operator  to  have  an  unobstructed  view  of 
the  lens  and  wound;  also  to  give  him  access 
to  the  angles  of  the  wound  and  tlie  summit 
when  replacing  the  cut  sides  of  the  iris, 
and  the  ai)r()n  of  tlie  iris  that  adheres  to 
the  scleral  wound  after  delivery.  (De- 
scription and  illustration  by  Vail.) 


Fig.  379. ^Smith's  operation  for  cat- 
aract: Shows  where  the  bulbous  end  of  the 
lens  hook  is  applied  in  the  act  of  pressing 
to  expel  the  lens.  The  pressure  is  made 
"straight  back  toward  the  optic  nerve." 
not  quickly  or  plungingly,  but  with  in- 
telligent and  boUl  onward  pressure,  never 
varying  the  direction  of  the  pressure  until 
either  tlie  lens  breaks  from  its  moorings 
.•ibove  or  below  and  shows  a  disposition  to 
be  delivered,  in  whicli  case  the  exit  jis 
favored  by  shifting  the  pressuie,  or  (the 
lens  Btubbornly  refuses  to  yield  and  ad- 
vance because  of  tough  iiganients  or  small 
size  of  the  incision.  (Desfrijttion  and 
illustration  by  Vail.) 


If  the  tension  of  the  eye  is  low,  tlie  emerging  lens  should  be  followed  with  a 
spatula  a.s  well  as  with  a  hook,. and  sometiines,  in  these  circumstances,  a  light 
counterprcssurc  with  a  spatula  aliove  the  wound  is  indicated. 

In  the  ca.se  of  intumescent  len.ses  and  Morgagnian  cataract,  the  cnpstiles  of 
which  are  e.xtremcly  delicate  and  liable  to  burst,  pressure  with  the  point  of  the 
Btraliisiiius  hook  is  made  suflieieiitly  dee|)  over  the  lower  border  of  the  lens  to  cause 
it  to  dislocate  l>elo\v  and  turn  a  half  Honu'rsault,  the  pressure  and  traction  always 
being  made  over  the  zonula.      As  soon  a.s  the  lens  turns  up  into  the  wound  the 


EXTRACTION  OF  HARD  CATARACT  737 

operator  ceases  to  make  traction  toward  the  patient's  feet  and  directs  the  pressure 
backward,  next  backward  and  upward,  and  finally  more  and  more  toward  the 
wound,  folding  the  cornea  beneath  the  lens  until  it  falls  outside  of  the  cornea. 
As  the  capsule  has  not  yet  been  dislocated  from  the  zonula  in  the  neighborhood  of 
the  woimd,  the  hollow  of  the  curve  of  the  strabismus  hook  should  be  made  to  sweep 
along  between  the  lens  and  the  wound  to  complete  this  detachment.  It  is  advisable 
in  these  circumstances  to  keep  up  sufficient  tension  on  the  eyeball  with  the  spatula 
placed  on  the  cornea  in  order  to  prevent  the  lens  from  slipping  back  into  the  eye. 

Hypermature  cataract  is  difficult  to  dislocate,  and  the  operator  should  proceed 
with  the  strabismus  hook  as  in  the  case  of  immature  and  hard  cataract,  but  a 
spatula  in  his  left  hand  should  be  in  position  at  the  margin  of  the  wound  to  drop 
behind  the  lens  the  instant  its  edge  appears.  As  it  is  dropped  almost  straight  down 
into  the  eye,  the  back  of  the  spatula  must  be  placed  against  the  sclerotic  margin  of 
the  wound  and  the  lens  pressed  against  it  with  the  hook  from  the  outside.  The 
lens,  therefore,  slides  along  the  inclined  plane  of  the  spatula. 

Great  care  should  be  taken  to  return  the  iris  to  its  proper  position,  whether  or 
not  an  iridectomy  has  been  made,  and  with  a  suitable  repositor  the  operator  should 
release  any  part  of  the  iris  from  the  sclera  or  from  the  angles  of  the  wound.  If 
this  is  carefully  done,  the  eye  need  not  be  dressed  until  the  expiration  of  the  eighth 
day,  and  many  of  the  complications  which  have  been  described  may  be  attributed 
to  meddlesome  dressings  and  meddlesome  inspections.  If  vitreous  escapes,  it 
should  be  snipped  off  with  the  scissors  in  the  usual  manner. 

According  to  Colonel  Smith,  cataracts  occurring  in  children  and 
young  persons  are  not  suited  to  this  operation,  because  it  is  practically 
impossible  to  dislocate  their  lenses.  The  operation  is  indicated  in 
unripe  cataract,  and  in  those  forms  of  cataract  which  are  immature 
and  which  require  long  periods  of  time  for  their  complete  opacification 
(see  also  page  445).  Much  difference  of  opinion  exists  as  to  the  v^alue 
of  this  operation  and  its  permanent  place  in  surgical  practice.  In 
this  country  it  has  been  commended  by  a  number  of  surgeons  (Vail, 
Timberman,  W.  A.  Fisher,  A.  S.  Green,  L.  D.  Green  and  others). 

One  of  the  objections  to  the  Indian  operation  is  that  the  percentage 
of  loss  of  vitreous  is  much  higher  than  in  the  ordinary  extractions  of 
cataract.  Colonel  Smith  has  reported  his  vitreous  loss  to  be  8  per 
cent.,  while  Vail,  in  a  series  of  uncomplicated  cataracts,  did  not  exceed 
2  per  cent,  of  vitreous  loss,  and  therefore  he  believes,  to  use  his  own 
expression,  that  vitreous  escape  is  not  the  argument  to  be  used  against 
Smith's  technic.  W.  A.  Fisher,  although  admitting  the  disadvantage 
of  frequent  vitreous  loss,  believes  this  can  be  overcome  by  careful 
technic  and  that  Smith's  operation  should  be  the  procedure  of  choice. 
Naturally,  the  ordinary  accidents  of  cataract  extraction  are  liable  to 
occur,  but  apparently  in  Smith's  Indian  service  they  are  not  greater 
than  those  which  occur  in  ordinary  extraction.  It  is  the  author's 
impression,  based  on  a  very  limited  experience  and  upon  his  observa- 
tion of  certain  operators  who  are  familiar  with  the  Smith  technic,  that 
while  this  operation  will  retain  a  place  in  ophthalmic  surgerj',  especially 
in  the  extraction  of  unripe  cataracts,  it  is  not  likeh'  to  drive  from  the 
field  those  procedures  which  have  for  years  been  firmly  and  favorably 
established. 

Several  operations  for  the  extraction  of  cataract  in  the  capsule 
after  subluxation  of  the  lens  with  capsule  forceps  have  been  devised. 

47 


738  OPERATIONS 

Arnold  Knapp's  Method. — "After  tlie  usual  preparation  and  the  instillation  of 
1  drop  of  utropin,  under  holocain  anesthesia,  the  Koster  speculum  is  introduced 
and  left  in  place  until  the  operation  is  completed,  unless  there  is  danger  of  or  actual 
prolapse  of  vitreous.  An  assistant  is  necessary  only  in  the  presence  of  complica- 
tions. The  section  must  be  large  and  should  be  just  short  of  half  the  corneal 
circumference  with  a  conjunctival  flap.  After  the  iridectomy,  the  capsule  forceps 
is  introduced  to  a  point  below  the  center  of  the  pupil,  the  branches  are  then  allowed 
to  separate  broadly,  and  a  distinct  knuckle  of  capsule  is  grasped.  The  grasp 
should  not  be  too  tight  lest  the  capsule  be  torn,  but  sufficiently  firm  to  exert  trac- 
tion on  the  periphery  of  the  lens  capsule.  The  closed  branches  of  the  forceps  are 
gently  moved  from  side  to  side,  up  and  down  or  rotated,  and  the  capsule  can  be 
seen  to  follow  in  the  various  directions.  When  the  dislocation  has  succeeded,  a 
part  of  the  margin  of  the  cataract  in  the  capsule  appears  free  in  the  pupillary  space. 
The  portion  dislocated  is  usually  below,  generally  slightly  to  one  side  or  the  other, 
with  the  upper  attachment  unruptured.  The  forceps  is  then  released  and  with- 
drawn. Pressure  is  exerted  straight  back  on  the  lower  part  of  the  cornea  with 
Smith's  hook,  and  the  cataract  can  be  seen  to  turn  a  somersault;  it  ''tumbles,"  in, 
other  words,  as  Smith  calls  it,  and  is  delivered  feet  first.  WTien  the  entire  lens  baa 
been  delivered,  it  will  be  found  adherent  above,  where  it  is  finally  separated  by  a 
lateral  stroking  motion.  In  some  cases  the  head  presents  first;  the  delivery  is  then 
slower,  and  counterpressure  must  be  applied  at  the  scleral  margin.  The  iris 
columns  are  then  carefully  replaced.  The  coloboma  should  ultimately  not  appear 
any  different  from  that  after  an  ordinary  extraction." 

Stanculeanu  has  devised  and  recommended  a  similar  operation. 
With  extraction  of  cataract  in  the  capsule  after  subluxation  of  the 
lens  with  capsule  forceps  by  any  of  the  methods  in  vo^ue  the  author 
has  had  little  practical  experience,  but  as  far  as  observation  permits 
him  to  judge,  Knapp's  method  is  the  most  satisfactory. 

To  prevent  iris  and  vitreous  prolapse  a  number  of  operators  have 
placed,  prior  to  the  extraction,  a  suture,  KalCs  corneal  suture  in  this 
regard  being  well  and  favorably  known.  The  point  of  a  sharp  needle, 
armed  with  fine  linen  thread,  is  passed  into  and  out  of  the  substantia 
propria  on  one  side  of  the  proposed  section  and  next  obliquely  through 
the  opposite  border  of  the  limbus  and  througli  the  scleral  tis.sue.  The 
loop  thus  formed  is  drawn  aside,  the  incision  completed,  and  after  the 
delivery  of  the  lens  the  threads  are  tied  in  a  single  knot.  Sliding 
conjunctival  flaps,  which  cover  the  line  of  incision,  for  example,  the 
Xnn  Lint  flap,  recommended  in  certain  cases  by  L.  Webster  Fox,  have 
also  ])Qon  used  to  pr(>vent  iris  jjrolapse  and  infection.  A  number  of 
operations  whereby  a  subconjunctival  extraction  of  cataract  is  performed 
have  been  devised,  for  example,  by  Dimmer,  antl  in  tliis  country  by 
the  late  Dr.  Frank  Todd.  Some  oixTators  as  a  rule  form  a  con- 
junctiral  bridge  beneath  wliich  the  lens  is  extracted,  (UfTering,  thi're- 
fore,  from  a  hirge  conjunct i\;il  !l;ip  in  its  shnix'  and  becnusc  its  upi)er 
end  remains  undivided. 

Anomalies  in  the  Healing  Process  after  Cataract  Extractions. — 
Pain.  Should  ])ain  occur  and  not  lie  due  to  the  circumstances  ah'(^ad>' 
UK^ntioned,  but  beconu^  violent  in  cli:iracter,  eitluM-  in  the  earlier  stages 
after  tiie  o))er;ifion  or  some  d;i\s  .-irteiward,  one  of  tlirc>(>  things  ni:iy  be 
apprehended:  intr;i-ociil;ii-  henioi  ih;ige,  sui)])ur;it  ion  of  the  wound,  or 
iritis. 


EXTRACTION  OF  HARD  CATARACT  739 

Expulsive  Intra-ocular  Hemorrhage. — Usually,  soon  after  the  opera- 
tion has  been  completed,  the  patient  complains  of  very  severe  pain,  or 
vomiting  may  occur  and  the  dressings  begin  to  be  stained  with  blood. 
On  removal  of  the  bandage  a  clot  of  blood  will  be  found  protruding 
through  the  palpebral  fissure,  and  on  raising  the  lid  the  anterior  cham- 
ber is  seen  to  be  full  of  blood  and  the  corneal  wound  gaping  widely. 
As  soon  as  the  symptoms  of  this  accident  are  manifest,  the  patient 
should  be  placed  in  an  upright  position  and  a  hypodermic  injection  of 
morphin  administered.  The  blood  should  be  carefully  removed,  the 
conjunctival  sac  washed  out  with  a  bichlorid  solution  (1  :8000),  and  a 
full  antiseptic  dressing  applied.  The  dressings  should  be  changed  once 
or  twice  daily.  In  this  way  it  may  be  possible  to  avert  suppuration, 
even  though  the  eye  remains  blind.  If  the  hemorrhage  should  con- 
tinue and  the  pain  become  intense,  enucleation  is  necessary. 

Anterior  Chamber  Hemorrhage. — Not  very  infrequently  hemorrhage 
takes  place  in  the  anterior  chamber  (about  4.5  per  cent,  in  Wheeler's 
statistics),  usually  soon  after  the  extraction,  but  sometimes  at  later 
periods,  some  as  late  as  one  month.  Such  hemorrhages  are  often 
the  result  of  slight  injuries;  albuminuria,  glycosuria  and  arterio- 
sclerosis are  predisposing  causes.  The  bleeding  may  be  spontaneous 
and  is  sometimes  recurrent.  Usually  the  hemorrhage  disappears 
rapidly;  hot  compresses  help  to  dissipate  it;  lactate  of  calcium  may 
be  administered. 

Suppuration  of  the  Wound. — According  toTreacher  Collins,  purulent 
infection  is  more  common  in  old  people  than  in  young,  and  the  tendency 
is  greater  between  sixty  and  seventy  than  between  seventy  and  eighty, 
though  it  is  certainly  greater  between  eighty  and  ninety  than  between 
sixty  and  seventy.  It  may  be  caused  by  lacrimal  complication,  in- 
flammation of  the  upper  respiratory  tracts,  sinus  disease,  conjunc- 
tivitis, blepharitis,  by  infection  introduced  at  the  time  of  the  operation; 
or  during  the  first  dressing  of  the  eye,  for  example,  a  non-sterile  atropin 
solution.  Suppuration  commences  on  the  first,. second,  or  third  day, 
more  rarely  on  or  after  the  fifth  day,  but  sometimes  as  late  as  the  thir- 
teenth day. 

The  symptoms  are  pain,  swelling  of  the  lids,  chemosis  of  the  con- 
junctiva with  undue  secretion,  haziness  of  the  cornea,  turbidity  of  the 
aqueous,  and  the  formation  of  a  slough  along  the  margins  of  the  wound. 

Two  terminations  are  possible:  The  suppurative  process  may  be 
limited,  so  that  at  the  end  of  the  inflammation  the  pupil  is  closed  and 
the  iris  drawn  upward,  or  the  entire  globe  may  participate  in  a  general 
destructive  inflammation  (purulent  panophthalmitis). 

If  the  suppuration  is  limited  to  the  margin  of  the  wound,  prompt 
treatment  may  be  of  avail.  The  conjunctival  sac  should  be  carefully 
disinfected,  the  lips  of  the  wound  gently  parted  after  removal  of  the 
slough  and  irrigated  with  a  bichlorid  solution,  and  the  whole  line  of 
incision  freely  cauterized  with  the  actual  cautery  or  with  liquid  carbolic 
acid.  In  other  words,  the  treatment  is  practically  that  which  has  been 
advised  for  a  sloughing  ulcer.     At  each  subsequent  dressing  the  lips 


•40 


OPERATIONS 


of  the  wound  should  be  parted  with  a  probe,  and  the  anterior  chamber 

drained.  Arp;yrol  sohition  (25  per  cent.)  may  be  in.stilled  into  the  con- 
junctival sac,  and  its  introduction  into  the  anterior  charnlx'r  has  been 
advised.  Hansell  recommends  the  injection  into  the  anterior  chamber 
of  a  few  drops  of  a  solution  of  bichlorid  of  mercury  (1  :  lOOOj.  Ziegler 
advises  the  constant  application  of  ice  (which  is  undoubtedly  superior  to 
hot  compresses  so  often  advised)  and  the  application  of  formalin  to 
the  wound  and  its  injection  into  the  anterior  chamber.  Subconjunc- 
tival injections  of  bichlorid  of  mercury  or  cyanid  of  mercury  have  been 
recommended  in  these  circumstances,  and  the  introduction  of  iodoform 
into  the  anterior  chamber  has  been  suggested,  and  successes  have  been 
reported.  In  recent  times  postoperative  suppuration  has  been  treated 
with  vaccines;  for  example,  the  injection  of  Wright's  antistaphylococcic 
vaccine,  or  antidiphtheritic  serum  (see  page  275).  A  bacterin  prepared 
from  the  micro-organism  which  is  active  has  in  more  than  one  instance 


Fig.  380. — Section  of  an  eye  with  postoperative  infection  which  began  on  the  ninth 
day  after  spontaneous  reopening  of  the  wound.  Notice  the  dense  infiltration  of  the 
wound  edges  and  that  the  lens  capsule  has  been  caught  in  this  material  between  the 
lips  of  the  wound. 

proved  highly  successful,  and  should  certainly  be  given  full  triiil. 
The  bacterin  treatment  may  be  combined  with  the  internal  administra- 
tion of  urotropin.  Should  the  infecting  micro-organism  prove  to  be  the 
pneumococcus,  ethylhydrocuprein  may  be  tried  (see  page  276). 

If  the  infection  manifests  itself  in  the  form  of  a  rimj  ahscess.  treat- 
ment is  usually  unavailing,  and  the  eye  passes  into  a  state  of  panoph- 
thalmitis and  requires  the  treatment  for  that  condition  which  has  al- 
ready been  detailed.  Suppuration,  instead  of  beginning  in  the  cornea, 
may  sometimes  connnence  in  the  iris  and  even  in  the  vitrtM)us.  anil  the 
process  go  on  to  a  raj)id  destructive  pMiioplilh:ilmitis.  It  is  a  clinical 
fact  that  if  one  eye  lias  been  lost  on  account  of  postoperative  suppura- 
tion, the  other  eye,  if  submitted  to  operation,  is  in  gniNc  danger  of 
meeting  a  similar  fate. 

Iritis  (tnd  Iridon/clitis.-  It  is  not  unconinion  l"oi-  ;it  tachnicnts  to 
form  between  the  c;ii)sule  ot  the  lens  and  the  margin  ot'  the  i)Upil  or  of 


i 


I 


EXTRACTION  OF  HARD  CATARACT  741 

the  coloboma.  These  sj'nechiae  usually  are  not  of  serious  consequence. 
Iritis  itself,  with  the  usual  symptoms  of  this  condition,  generally  sets 
in  about  the  fifth  day,  but  may  be  delayed  to  the  tenth  day.  It  has 
been  attributed  to  an  imperfect  toilet  of  the  wound,  with  the  retention 
of  pieces  of  cortex,  and  sometimes  by  too  early  exposure  of  the  eye,  but 
really  should  be  regarded  as  a  manifestation  of  infection.  If  the  ciliary 
body  becomes  involved  and  an  iridocyclitis  is  set  up,  the  gravity  of  the 
situation  increases  and  the  process  may  terminate  in  distortion  and 
closure  of  the  pupil,  with  exuded  lymph.  Iridocyclitis  may  last  for 
weeks,  the  inflammatory  symptoms  varying  in  their  intensity,  but 
finally  the  iris  becomes  dull  and  discolored  and  there  is  grave  danger 
of  sympathetic  trouble  in  the  opposite  eye.  Indeed,  sympathetic 
ophthalmitis  in  these  circumstances  has  been  reported  a  number  of 
times.  Late  cyclitis — that  is,  an  inflammation  occurring  after  the  first 
week — is  characterized  by  deep-seated  circumcorneal  injection,  thicken- 
ing and  opacity  of  the  capsule,  and  posterior  synechise.  Under  treat- 
ment the  symptoms  may  subside  or  secondary  glaucoma  may  develop. 
The  treatment  of  these  conditions  in  general  terms  should  include 
bleeding  from  the  temple  by  means  of  leeches,  the  free  use  of  atropin, 
dionin,  holocain,  hot  fomentations  (usually  recommended,  but  iced 
packs  generally  are  more  satisfactory  than  heat),  the  internal  adminis- 
tration of  large  doses  of  saUcylate  of  sodium,  and  in  most  circumstances 
mercury  and-  iodid  of  potassium.  A  number  of  observers  have  ob- 
tained good  results  from  the  administration  of  neosalvarsan.  If  the 
process  closes  the  pupil,  after  the  eye  becomes  quiet  iridectomy,  iri- 
dotom}',  or  iridocystectomy  may  be  required. 

A  remarkable  condition  to  which  H.  Knapp  called  special  attention 
is  the  formation  of  a  spongy  or  gelatinous  exudation  in  the  anterior 
chamber,  associated  at  first  with  considerable  pain,  congestion  of  the 
conjunctiva,  and  edema  of  the  margins  of  the  hd.  The  manifestations 
are  those  of  spong}'  iritis  without  an  inflammation  of  the  iris.  Several 
times  the  author  has  observed  this  complication.  The  exudation  dis- 
appeared and  the  result  was  good,  although  at  first  the  appearances 
were  most  alarming. 

Bulging  or  Cystoid  Cicatrix. — Instead  of  perfectly'  smooth  heahng, 
the  cicatrix  at  the  end  of  a  week  or  two  may  begin  to  bulge,  sometimes 
at  one  or  other  extremit}'  of  the  wound,  and  sometimes  through  its 
entire  length.  The  bulging  consists  in  a  vesicle-like,  semitransparent 
elevation,  and  is  generally  associated  with  an  entanglement  of  the  iris 
in  its  margins,  together  with  distortion  of  the  coloboma.  Eyes  in 
which  such  entanglement  of  the  iris  has  taken  place  are  likely  to 
develop  iridokeratitis,  and  it  has  been  recommended  that  the  cystoid 
cicatrix  should  be  removed  and  the  opening  closed  by  the  apphcation  of 
the  electro-  or  thermocautery.  This  procedure,  however,  has  proved 
to  be  a  dangerous  one  in  several  instances,  and  has  been  followed  bj- 
severe  inflammation  and  even  by  sympathetic  ophthalmia. 

Glaucoma  after  Extraction. — This  complication  occurs  after  a  severe 
iritis,  with  numerous  posterior  synechise,  which  has  led  to  the  forma- 


742  OPERATIONS 

tion  of  a  membrane.  It  may  be  the  sequel  of  an  iritis,  which  is  charac- 
terized by  a  deep  anterior  chamber  and  dotted  opacities  on  the  cornea,  or 
also  of  an  iritis  which  is  only  slight  in  character,  but  where  there  has 
been  an  adherence  of  the  pillars  of  the  coloboma  to  the  cicatrix  and 
also  to  the  lens-capsule,  or  where  tags  of  capsule  have  attached  them- 
selves to  the  under  surface  of  the  corneal  wound  (see  also  page  424). 
This  tends  to  obliterate  the  canal  of  Schlemm.  Glaucoma  may  be 
caused  by  imperfections  in  technic  and  by  obstruction  caused  by 
remnants  of  capsule  and  iris,  and  is  prone  to  follow  slow  closure  of  the 
wound  and  the  formation  of  an  anterior  synechia.  Elschnig's  in- 
vestigations show  that  this  condition  may  arise  by  reason  of  a  pro- 
liferation of  epithehal  cells  within  the  anterior  chamber— that  is,  by 
an  abnormal  ingrowth  from  the  anterior  corneoscleral  surface.  Glau- 
coma of  similar  origin  also  occurs  after  the  operation  of  laceration  of 
the  capsule — i.  e.,  after  discission.  If  uncontrolled  by  miotics,  iridec- 
tomy, sclerotomy,  or  cj^lodialysis  should  be  performed. 

Opacities  of  the  Cornea  and  Keratitis. — Opacity  in  the  cornea  may 
be  due  to  the  introduction  of  antiseptic  fluid,  especially  solutions  of 
bichlorid  of  mercury,  into  the  anterior  chamber.  It  has  a  peculiar, 
milky-white  appearance,  and  is  located  chiefly  at  the  posterior  surface 
of  the  cornea,  although  the  epithelium  may  also  be  rough.  It  does  not 
disappear,  and,  if  sufficiently  thick,  entirely  vitiates  the  effect  of  the 
operation. 

This  opacity  must  not  be  confounded  with  a  very  common  type  of 
keratitis  occurring  after  cataract  extractions,  which  has  received  the 
name  striated  keratitis,  consisting  of  fine  stripes  of  opacity  radiating  in 
several  directions  across  the  cornea.  This  entirely  disappears  in  a  few 
days,  and  need  not  give  rise  to  apprehension.  As  Frederick  Tooke 
points  out  in  his  admirable  studies  of  the  pathology  of  the  corneal 
section,  this  condition  is  more  common  in  elderly  subjects  than  in  those 
of  younger  years,  and  may  be  due  to  alterations  in  the  endothelium  or 
in  Descemet's  membrane  dependent  on  age,  which  permit  access  of 
aqueous  through  the  cells,  the  tension  having  been  released  by  the 
corneal  section.  Occasionally  at  the  end  of  a  week  or  more  herpes  of 
the  cornea,  heralded  by  sharp  j)ain  and  lacrimation,  may  develop,  and 
from  the  herpetic  spots  small  filaments  may  ixviso—fihunentous  keratitis. 
The  lesions  will  subside  under  the  infiuence  of  light  bandages  and  anti- 
septic lotions;  holocain  is  of  much  service. 

Prolapse  of  the  Iris. — This  complication  is  the  chief  objection  to  the 
operation  of  sim])le  extraction,  and  varies  in  fre([uencv  from  'A  to  10 
per  cent.,  according  to  dilTerent  statistics.  Th(>  i)rolai)se  is  usually 
heralded  by  a  sudden  sharp  pain,  which  graduall}^  passes  away.  It 
generally  results  from  trauma — -for  example,  striking  the  hand  against 
th(!  ej'e — or  is  due  to  a  fit  of  coughing,  violent  exertion,  straining  elTort, 
or  similar  cause.  If  the  ])rolaps('  is  discovered  soon  after  its  occur- 
rence— that  is,  at  the  first  dressing-  it  should  be  cut  olT  and  the  edges 
of  the  iris  reduced,  exactly  as  after  the  operation  of  iridectomy.  If 
the  proljipse  is  not  notcil  until  the  tliinl  oi'  fourth  day.  it  is  soiiictinies 


EXTRACTION    OF   HARD    CATARACT  743 

proper  to  allow  it  to  remain.  The  eye  should  be  firmly  but  gently 
bandaged  and  atropin  may  be  instilled,  although  some  surgeons  prefer 
eserin.  Small  prolapses  may  disappear,  others  produce  no  irritation^, 
while  still  others  become  larger,  constricted  at  their  bases  or  cystoid^ 
H.  Knapp  allowed  these  to  remain  until  the  irritation  had  disappeared, 
and  then  amputated  them  in  the  same  manner  as  a  small  staphyloma  is 
abscised,  and  usually  obtained  smooth  and  permanent  recovery.  Oc- 
casionally iridocyclitis  occurs,  and  sympathetic  ophthalmitis  has  been 
reported.  In  general  terms  the  safest  procedure  is  to  excise  the  pro- 
lapsed iris  as  soon  after  its  discovery  as  possible. 

Prolapse  of  the  iris  after  combined  extraction — i.  e.,  entangle- 
ment of  the  edge  of  the  cut  iris  in  the  angle  of  the  wound — is  not 
uncommon. 

Delayed  Restoration  of  the  Anterior  Chamber  and  Delayed  Healing. — 
Often  the  wound  after  cataract  extraction  is  closed  at  the  end  of 
twenty-four  hours,  usually  not  later  than  the  third  day.  Occasionally, 
however,  there  is  delayed  restoration  of  the  anterior  chamber,  which 
in  most  instances  is  caused  by  some  foreign  substance — for  example,  a 
particle  of  capsule  or  conjunctiva  between  the  lips  of  the  wound,  or  to 
an  almost  imperceptible  incurvation  of  the  flap  (Trousseau) .  Doubt- 
less, in  most  cases,  an  error  in  the  technic  of  making  the  section  is 
responsible  for  slow  closure  of  the  wound.  In  a  few  instances  the 
failure  to  unite  appears  to  be  due  to  excessive  secretion  of  aqueous 
humor  or  to  lack  of  reparative  power,  depending  upon  some  anomaly 
in  the  condition  of  the  patient.  Derrick  Vail  attributes  this  complica- 
tion to  an  involuntary  spastic  contraction  of  the  orbicularis  and  has 
remedied  it  by  severing  the  muscle,  cutting  directly  upward  and  down- 
ward, from  its  external  attachment.  A  conservative  treatment  is 
generally  indicated,  and  it  is  usually  recommended  that  bandaging  and 
rest  in  bed  shall  be  continued  until  the  chamber  is  restored,  but  the 
author  agrees  with  Berry  that  if  any  dressing  be  applied  at  all,  if  the 
wound  does  not  close  readily,  it  should  be  of  the  lighest  character 
and  should  exert  no  pressure  on  the  lids.  Usually  removal  of  the 
bandage  and  the  adjustment  of  protecting  spectacles  (wire-gauze) 
facilitates  the  healing  (Gifford) .  If  a  piece  of  capsule  or  other  foreign 
substance  can  be  detected,  it  should,  of  course,  be  removed.  A  light 
cauterization  of  the  line  of  incision  with  a  point  of  nitrate  of  silver 
or  a  probe  dipped  in  carbolic  acid  is  often  of  service.  Delayed  union 
of  the  wound,  especially  after  corneal  incisions,  with  separation  of^its 
margins,  may  end  in  recovery,  but  has  been  followed  by  infection  and 
by  glaucoma,  especially  if  the  lens  capsule  becomes  adherent  to  the 
corneal  wound.  Associated  with  tardy  or  imperfect  wound  closure 
there  may  be  a  glossy  edema  of  the  conjunctiva  in  its  lower  part,  which 
H.  Knapp  called  filtration  chemosis.  It  will  subside  when  the  union  of 
the  incision  is  firm. 

Postoperative  Delirium  and  Insanity. — Delirium  after  operation  has 
been  referred  to.  Sometimes  marked  dementia  follows  cataract  ex- 
traction.    The  delirium  has  been  ascribed  to  the  use  of  the  bandage,  to 


744 


OPERATIONS 


the  effect  of  atropin,  to  imperfect  mental  balance  existing  prior  to  the 
operation,  and  to  auto-intoxication.  If  possible,  the  bandage  should 
be  removed  and  the  patient  given  various  sedatives,  e.  g. — the  bromids 
— according  to  the  indications.  Paraldehyd  is  useful;  morphin  usu- 
ally does  not  act  well  in  these  circumstances. 

Choice  of  an  Operation. — 01)viously,  the  advantages  of  simple 
extraction  are  the  absence  of  mutilation  of  the  iris,  and  consequently 
the  formation  of  a  round  pupil  which  reacts  freely  to  the  changes  of 
light  and  shade  and  prevents  the  dazzling  caused  by  the  presence  of  a 
coloboma.  Its  disadvantages  are  the  difficulty  of  expelling  the  lens, 
the  increased  difficult}'  of  performing  perfect  toilet  of  the  wound,  and 
the  danger  of  prolapse  of  the  iris.  In  the  judgment  of  the  author  cer- 
tain cases  require  iridectoni}' — namelj-,  those  in  which  the  ball  is  hard, 
the  lens  is  large,  the  anterior  chamber  is  shallow,  the  iris  is  not  readily 
dilatable,  or  there  is  ciliary  irritation.  The  combined  method  is  also 
preferred  if  the  cataract  is  not  ripe  or  if  the  patient's  mental  or  physical 
condition  tends  to  create  restlessness.  In  other  circumstances  simple 
extraction  may  be  performed,  and  this  was  the  author's  practice  until 
within  the  last  few  years.  He  has,  however,  returned  to  combined 
extraction  with  a  small  iridectoni}',  as  it  is,  on  the  whole,  a  more  satis- 
factory procedure.  For  the  reasons  already  given  the  author  is  unable 
to  agree  with  those  surgeons  who  believe  extraction  of  the  lens  in  its 
capsule  should  necessarily  be  the  operation  of  choice,  although  he 
fully  recognizes  the  advantages  of  intrascapular  extraction,  and,  as 
before  noted,  has  been  especially  impressed  with  the  technic  de- 
veloped by  A.  Knapp  (page  738). 

The  method  of  Barraquer  (phakoerisis) ,  whereby  the  lens  in  its 
capsule,  after  a  suitable  section,  is  withdrawn  with  the  aid  of  a  spe- 
cially devised  suction  apparatus  (erisophake)  has  attracted,  recently, 
much  attention.'  With  this  procedure  the  author  has  hail  no 
experience. 

Cataract  extraction  without  iridectomy  may  be  performed  accord- 
ing to  Chandler's  method,  in  which  a  small  piece  of  iris,  1  mm.  in 
diameter,  is  removed,  making  a  very  small,  round  opening  as  near  the 
j-oot  of  the  iris  as  jjossiblc.  This  facilitates  drainage  and  prevents  iris 
I^rolapse.  In  Angelueci's  modification  of  cataract  extraction  fixation 
is  on  the  superior  rectus  muscle,  and  the  cut  lie  operation  is  com- 
pleted without  speculum  or  aid  of  assistant. 

Prelim inarif  Iridectuftn/. — Some;  operators,  almost  as  a  rule,  perform 
a  preliminar}'  irideclom}'  and  extract  the  catar.-ict  sev(>ral  weeks  later, 
because  by  this  method  the  dangers  of  the  tinal  operation  are  le.><seneil. 
It  ia  to  be  recommended  in  any  case  where  serious  complications  are 
ap])rehended,  where  for  any  reason  an  extraction  in  one  vyr  has  ter- 
MiiiiatcMJ  unfavorably,  or  where  the  cataract  is  not  ripe. 

I'relinniKini  ('(t/jsiilolonn/.     Operative  procedures  designed  for  the 

[jurpose  of  rijx'ning  immature  cataract    are  described  on  i)age  -14"). 

'  ('oriHult  Americiiii  Journal  of  OptitliiilinoloK.v,  (Vtoher,  1920.  In  this  Hrticle 
M:iirii<iii('r  fully  illiistnitcs  his  technic. 


OPERATIONS  FOR  AFTER-CATARACT  745 

Homer  E.  Smith  advises  preliminary  capsulotomy  and  operates  as 
follows : 

The  capsulotomy  knife  is  thrust  through  the  middle  of  the  superotemporal 
quadrant  of  the  right  cornea  and  is  made  to  reach  the  lowest  point  of  the  dilated 
pupil  and  to  rest  on  the  vertical  meridian  of  the  lens.  The  handle  is  now  raised 
until  the  blade  penetrates  the  capsule.  Next,  the  handle  is  made  to  describe  an  arc 
of  a  circle  away  from  the  operator,  the  capsule  being  incised  along  the  vertical 
meridian,  whUe  the  shank  is  gradually  withdrawn.  The  point  of  the  knife  is  next 
released,  the  shank  introduced,  the  blade  carried  to  the  nasal  margin  of  the  pupil, 
and  the  capsule  incised  along  the  horizontal  meridian.  If  the  left  eye  is  to  be  oper- 
ated upon,  the  knife  is  entered  in  the  temporo-inferior  quadrant  of  the  cornea  and 
the  first  incision  is  from  above  downward.  Eserin  (gr.  1^  to  f  5j — 0.097  gm.  to 
30  c.c.)  is  instilled  and  the  eye  bandaged.  At  the  expiration  of  six  hours  the  lens 
is  extracted  in  the  usual  manner.  The  object  of  this  operation  is  to  separate  the 
capsule  from  the  lens  and  bring  about  a  union  of  the  nucleus  and  of  the  cortex. 

Smith's  procedure  has  received  the  endorsement  of  a  number  of  sur- 
geons. Apparently  there  is  no  harm  in  extending  the  interval  between 
the  two  operations  to  twentj'^-four  hours  (Hansell  and  Shannon). 


Fig.  381. — Knapp's  knife-needle. 

Operations  for  After=cataract. — After-cataract — or,  as  it  is 
usually  called,  secondary  cataract — has  been  described.  If  it  is  a  deli- 
cate, web-like  membrane  which  stretches  across  the  pupil,  and  which  is 
best  seen  by  artificial  illumination — i.  e.,  condensing  with  a  large 
magnifying-glass  a  beam  of  light  into  the  pupillary  space — the  treat- 
ment may  consist  in  the  introduction  of  a  cataract  needle  in  the  manner 
described  under  Discission,  and  making  a  laceration  in  the  membrane. 
The  operation  is  readily  performed  with  H.  Knapp's  knife-needle 
(Fig.  381)  in  the  manner  advised  by  this  surgeon — namely: 

The  pupil  being  dilated  ad  maximum,  and  the  area  of  the  operation  being  per- 
fectly illuminated,  the  knife-needle  is  thrust  through  the  cornea  3  mm.  from  its 
margin  in  the  horizontal  meridian.  Next,  the  knife-needle  is  advanced  to  a  point 
close  to  the  opposite  margin  of  the  iris,  where  the  membrane  is  punctured,  and  a 
horizontal  incision  of  4  or  5  mm.  is  made.  This  being  accomplished,  the  point  of  the 
needle  is  raised  toward  the  cornea  and  passed  upward  in  front  of  the  membrane, 
which  it  transfixes  at  a  point  2  mm.  above  the  horizontal  incision,  and  divides  it  by 
a  cutting  movement  downward,  as  far  as  the  horizontal  incision.  The  same  proced- 
ure is  performed  on  the  lower  half  of  the  membrane,  cutting  from  below  upward. 
Thus,  a  crucial  incision  is  formed,  and  if  successful,  the  retraction  of  the  edges  leaves 
a  good  central  aperture  in  the  membrane.  It  is  essential  to  cut  the  after-cataract, 
and  not  to  tear  it  nor  drag  upon  the  ciliary  body.  Therefore  the  instrument  should 
avoid  thickened  portions  of  the  capsule.  It  is  also  desirable  that  it  should  not  enter 
deeply  into  the  vitreous. 

In  place  of  entering  the  knife  through  the  cornea  in  the  manner  already  de- 
scribed, the  puncture  may  be  made  through  the  conjunctiva  at  the  corneoscleral 
border,  a  method  which  the  author  is  accustomed  to  follow.  In  place  of  this 
operation,  Ziegler's  method  (see  page  698)  may  be  employed;  indeed,  in  recent 
5'ears  the  author  has  used  this  admirable  operation  almost  exclusively  in  all  types 
of  after-cataract. 


746 


OPERATIONS 


Where  the  membrane  is  thick  and  there  has  been  much  proUferation 
of  the  epithoHum,  discission  with  a  knife-needle,  owing  to  the  dense  and 
resisting  character  of  the  tissues  and  the  danger  of  dragging  upon  the 
ciharj'  bod}^  and  iris,  is  a  dangerous  operation.  In  these  circumstances 
iridotomy  or  Ziegler's  operation  should  be  employed  (see  jiage  098). 

Other  plans  are  to  divide  the  capsule  with  delicate  cannula  .scissora, 
or  to  cut  the  desired  opening  with  an  instrument  which  works  on  the 
principle  of  a  punch.  In  place  of  entering  the  knife  through  the  cornea 
or  corneoscleral  border  it  may  be  passed  through  the  sclera  6  mm. 
behind  the  corneal  margin,  and  pushed  forward  so  that  its  point  passes 
through  the  membrane  into  the  anterior  chamber.  The  membrane  is 
cut  by  causing  the  knife  to  make  a  sweeping  movement  from  before 
backward. 


Fig.  382. — Sections  of  secondary  cataract,  showing  inclusion  of  cortical  remnants 
between  the  posterior  and  anterior  capsule  and  curling  of  the  capsule  upon  itself. 
(From  a  specimen  prepared  by  Dr.  C.  M.  Hosmcr  in  the  author's  laboratorj-.) 

Discission  is  an  operation  invested  with  many  dangers.  In  no  cir- 
cumstances should  there  be  rough  handling;  the  discission  instruments 
must  be  very  sharp,  and  the  operator  must  avoid  dragging  ui)()n  resist- 
ing bands.  Preceding  the  oj^eration  and  following  it  there  should  be 
the  free  use  of  atropin.  If  signs  of  reaction  occur,  the  treatment  of 
iritis  is  indicated. 

Glaucoma  after  discission  is  an  occasional  complication,  and  is  char- 
acterized b}'"  pain,  steamy  cornea,  impaired  vision,  and  increasetl  ten- 
sion. It  should  be  treated  by  eserin  locally,  morphin  and  chloral 
internally',  and,  if  these  measures  fail,  by  iridectomy  or  paracentesis 
and  evacuation  of  the  vitreous  from  the  anterior  duunlxT. 

In  cases  of  occlusion  of  th(^  pupil  by  a  drawing  u))  of  the  iris,  tr 
where  there  are  bands  of  strong  irillammatory  lympii,  to  which  also  the 
name  secondary  cataract  is  sometimes  ai>plied,  discission  is  not  advis- 
able. In  most  instances  iridotomy  or  V-shaped  iridotomy  witii  a  knife- 
needle  is  ( h(!  best  operation 


f 


i 


COMPLETE  TENOTOMY 


747 


OPERATIONS  UPON  THE  EYE-MUSCLES 

These  consist  of  complete  and  partial  tenotomy  and  advancement  or 
readjustment,  and  advancement  with  muscle  resection.  For  the  operation 
of  tenotomy  the  following  instruments  are  required:  A  stop  speculum 
or  lid-elevator,  two  strabismus  hooks  (Figs.  383,  384),  fixation  forceps, 
and  a  pair  of  probe-pointed  scissors,  the  form  devised  by  Dr.  Jackson 
being  particularh'  suitable.  In  young  children  gen- 
eral anesthesia  ma}'  be  necessary;  but,  if  possible, 
cocain  should  be  used.  Usuallj'  the  internal  rectus 
is  divided;  quite  frequently  the  external  rectus;  less 
commonly  the  other  straight  muscles. 

Complete  Tenotomy. — In  a  tenotomy  on  the 
internal  rectus,  for  example,  the  operator  proceeds 
as  follows : 


Figs.  383,  384.— Stra- 
bismus hooks. 


The  eyelids  being  separated  with  a  stop  speculum,  the 
surgeon  catches  with  a  fine-toothed  forceps  a  fold  of  con- 
junctiva and  subjacent  fascia  on  a  level  with  the  lower 
border  of  the  tendon,  and  with  the  probe-pointed  scissors 
makes  an  opening  just  large  enough  to  admit  the  strabismus 
hook.  He  may  with  one  clip  divide  conjunctiva,  subjacent 
fascia,  and  the  capsule  of  Tenon;  otherwise,  after  the  division 
of  the  conjunctiva  and  subconjunctival  tissue,  Tenon's  cap- 
sule must  be  picked  up  and  incised  in  a  length  equal  to  the 
cut  made  in  the  overlying  structures.  A  strabismus  hook  is  next  passed  behind  the 
tendon,  its  point  turned  upward,  and  made  to  appear  at  the  upper  border  of  the 
tendon  beneath  the  conjunctiva.  It  is  next  drawn  forward  and  outward  toward 
the  cornea,  and  scissors,  with  their  blades  slightly  parted,  are  introduced  between 
the  hook  and  the  eye,  and  the  tendon  cut  close  to  its  sclerotic  attachment.  This 
is  the  subconjunctival  operation,  and  was  introduced  by  Critchett. 

Instead,  the  subconjunctival  method,  especially  in  cases  where 
there  is  a  considerable  squint,  the  open  operation,  or,  as  it  is  known,  the 
Graefe  method,  may  be  performed  as  follows: 

The  operator  seizes  with  fixation  forceps  a  fold  of  conjunctiva  and  subconjunc- 
tival tissue  parallel  with  the  corneal  margin  over  the  insertion  of  the  tendon  and 
divides  the  tissue  raised  by  the  forceps  horizontally  down  to  the  sclera.  Next  the 
point  of  a  strabismus  hook  is  pressed  firmly  against  the  sclera  below  and  behind  the 
insertion  of  the  tendon,  under  which  it  is  passed  until  it  reaches  its  upper  margin. 
With  the  hook  in  position  the  exposed  tendon  is  put  slightly  upon  the  stretch  and 
separated  from  its  attachment  by  means  of  blunt-pointed  scissors.  The  hook  is 
next  passed  with  its  point  turned  above  and  below  and  any  tendinous  fibers  which 
may  have  escaped  are  divided.  The  hook  should  now  pass  readUy  to  the  corneal 
margin.  Sutures  used  for  closing  the  wound  should  be  inserted  vertically,  unless 
it  is  desired  to  lessen  the  effect  of  the  operation,  in  which  case  they  are  placed  in  a 
horizontal  direction. 

After  tenotomy  the  conjunctival  sac  should  be  thoroughly  irrigated  with  boric 
acid  solution  or  bichlorid  of  mercury  (1  :  10,000)  and  both  eyes  bandaged  for  a  day 
or  two.  The  conjunctival  suture  may  then  be  removed  and  the  patient  wear  his 
correcting  glasses.  If  the  patient  is  in  suitable  surroundings,  a  bandage  may 
be  dispensed  with  and  the  spectacles  which  correct  the  refractive  error  may  be 
worn  immediately  after  the  operation.  The  latter  procedure  is  followed  by  the 
best  results. 


748 


OPERATIONS 


Snellen's  method  of  operating  is  satisfactory,  and  one  which  the 
author  often  employs.  A  small  opening,  about  4  mm.  in  width, 
is  made  through  the  conjunctiva  over  the  insertion  of  the  tendon, 
the  center  of  which  is  then  incised  vertically.  Through  this  opening 
the  point  of  a  strabismus  hook  is  inserted  and  the  upper  and  lower  half 
of  the  tendon  divided.  A  suture  closes  the  conjunctival  wound. 
Stevens'  method,  described  on  page  749,  is  a  modification  of  this  opera- 
tion and  may  be  used  for  complete  as  well  as  for  partial  tenotomies. 
Tenotomy  of  the  other  straight  muscles  may  be  performed  accord- 
ing to  the  methods  already  described,  the  operator  remembering  the 

distance  of  the  insertion  of  each 
tendon  from  the  corneal  margin 
(see  page  572). 

Tenotomy  of  the  Inferior 
Oblique. — This  operation  was 
originally  suggested  by  E.  Land- 
olt,  but  its  indications  and 
technic  have  been  especially 
elaborated  by  Duane.  Posey, 
who  has  made  a  valuable  con- 
tribution to  this  subject,  thus 
describes  the  operation: 

After  injecting  the  tissues  with  a  2 
per  cent,  solution  of  the  novocain,  a 
curvilinear  incision  is  made  just  su- 
perior and  parallel  to  the  lower  and 
inner  bony  rim  of  the  orbit,  the  tissues 
being  divided  down  to  the  bone.  A 
strabismus  hook  is  next  inserted,  and 
gentle  traction  is  made  on  the  tissues 
until  the  nmscle  is  encountered.  This 
is  assured  by  the  upward  movement 
imparted  to  the  globe  by  traction  on 
the  hook.  Tlie  tendon  is  next  drawn  forward  and  divided.  The  wound  having 
been  closed  with  one  or  two  stitches,  a  firm  dressing  is  applied  and  allowed  to  re- 
main in  place  for  forty-eight  hours.  Occasionally  a  subconjunctival  ecchymosis 
appears  at  the  lower  and  inner  i)art  of  the  globe;. 


Fig.  385. — Exposure  of  the  internal  rectus 
tendon,  which  is  lifted  upon  a  hook  (after 
Haab) .  This  drawing  also  illustrates  Prince's 
method  of  advancement  (see  page  752).  The 
suture  in  the  sclera,  to  which  the  tendon  is 
afterward  fas  ened,  is  seen  lying  along  the 
corneal  margin. 


The  indications  for  this  operation,  based  upon  Duane's studies, 
thus  summarized  by  Posey: 

(a)  ('omjilcte  stationary  paralysis  of  the  superior  rectus  (espcci; 
congenital  or  traumatic)  of  the  opposite  eye. 

{b)  Partial  i)aralysis  of  the  superior  rectus  of  the  opjxjsite  eye 
owing  to  fixation  being  performed  by  the  latter,  the  fellow  eye 
velops  a  spasm  of  the  inferior  oblique,  giving  rise  to  diplopia,  a  ( 
figuring  ui)shoot  of  the  alTected  eye,  or  a  histiug  torticollis. 

(c)  Si)asm  of  the  inferior  oldieiue,  either  secondary  to  paral>si,« 
the  superior  oblicpie  or  some  ot  lu  r  muscle  iti  t  lie  same  eye.  or  occurr 
as  a  ])rimary  condition,  ])rovid('(l  the  s\iiiploiiis  ;ire  sutliciciitly  ( 
turbiiig  to  w;irraiil  o|)('r;il  ion. 


are 


liiv 


if. 


Iis- 


mg 
lis- 


I 


PARTIAL  OR  GRADUATED  TENOTOMY  749 

Complications  in  Tenotomy  Operations. — 1.  The  operator  may  fail 
to  have  divided  the  capsule  of  Tenon.  In  these  circumstances  he  will 
also  fail  to  introduce  the  hook  beneath  the  tendon,  and  by  such  failure 
will  recognize  that  he  has  not  sufficiently  incised  the  tissues. 

2.  Hemorrhage. — Occasionally  severe  hemorrhage  follows  a  tenot- 
omy, the  blood  rapidlj'  pouring  out  beneath  the  capsule  of  Tenon 
and  causing  alarming  proptosis.  A  firm  pressure  bandage  should  be 
applied,  and  graduallj-  the  proptosis  will  subside  and  the  blood  be 
absorbed. 

3.  Orbital  Cellulitis  and  Tenonitis. — Cellulitis  has  occurred  from 
infection  of  the  wound,  the  inflammation  traveHng  back  and  causing 
an  inflammation  of  the  tissues  of  the  orbit.  The  treatment  of  orbital 
cellulitis,  described  in  another  section,  is  indicated.  Tenonitis,  or 
inflammation  of  the  orbito-ocular  fascia,  has  followed  squint  opera- 
tions. 

4.  Perforation  of  the  Sclera. — Although  this  is  a  rare  accident,  it  has 
happened  to  operators  of  considerable  experience  as  the  result  of  the 
use  of  sharp-pointed  scissors,  and  for  this  reason  the  probe-pointed 
instrument  is  always  to  be  preferred.  In  such  circumstances  the  eye 
should  be  treated  in  the  manner  described  on  page  318. 

5.  Retraction  of  the  caruncle,  so  that  it  sinks  away  from  its  normal 
position  and  gives  a  most  disagreeable  and  peculiar  stare  to  the  eye,  is  a 
very  unfortunate  occurrence  after  a  squint  operation.  A  very  shght 
degree  of  this  is  liable  to  occur  even  after  the  most  careful  tenotomy 
of  the  internus.  Where  it  exists  in  great  degree,  it  is  due  in  part  to 
excessive  dissection  of  the  tissues,  and  in  part  to  retraction  of  the 
muscle.  There  are  several  methods  of  overcoming  this  defect,  the 
essential  character  of  which  is  the  loosening  up  of  the  contracted  tis- 
sues and  stitching  the  caruncle  into  place. 

Partial  or  Graduated  Tenotomy. — Graduated  tenotomies  are 
performed  for  the  purpose  of  correcting  those  conditions  which  are 
described  under  Heterophoria .  The  operation  has  been  especially  elabo- 
rated by  Dr.  Stevens,  of  New  York,  and  is  performed  as  follows: 

With  a  pair  of  small,  narrow-bladed  scissors  a  transverse  incision  is  made 
through  the  conjunctiva  exactly  corresponding  to  the  line  of  insertion  of  the  tendon. 
This  is  seized  behind,  but  near  its  insertion,  and  a  small  opening  is  made  dividing  the 
center  of  the  tendinous  expansion  exactly  on  the  sclera.  This  opening  is  then 
enlarged  by  careful  cuts  with  the  scissors  toward  each  edge,  keeping  carefully  on 
the  sclera  as  the  border  of  the  tendon  is  approached;  the  amount  to  be  cut  depends 
upon  the  judgment  of  the  operator  and  the  need  of  the  case,  and  is  further  regulated 
by  placing  the  patient  before  a  lighted  candle  and  testing  the  sufficiency  of  the 
muscle  upon  which  the  operation  is  made,  in  the  manner  already  described  in 
connection  with  the  investigation  of  heterophoria.  In  dealing  with  strabismus,  the 
surgeon  may  determine  to  continue  his  section  through  the  border,  leaving  un- 
injured, as  far  as  possible,  both  the  anterior  and  posterior  lamellae  of  the  capsule,  as 
well  as  the  expansion  at  each  border,  to  hold  the  muscle  in  relation  to  the  eye. 
Turning  the  scissors  then  in  the  direction  of  the  other  border,  this  portion  is  dis- 
sected with  equal  care. 

Figures  386  to  391  illustrate  the  dehcate  instruments  which  are 
used  in  this  operation.     They  may  with  equal  proprietj'  be  employed 


750 


OPERATIONS 


in  ordinary  tenotomies,  and  are  satisfactory  for  this  purpose,  inas- 
much as  the  laceration  of  the  tissues  is  loss  marked,  while  the  effect 
is  equally  great  if  the  incisions  are  carried  sufficiently  far  according  to 
the  directions  already  given. 

Several  other  operative  procedures  for  the  purpose  of  elongating  the 
tendon  by  partial  tenotomies  have  been  designed,  especially  by  Ziegler, 
Verhoeff,  and  Todd.  The  first-named  surgeon  describes  the  character- 
istics of  his  operation  as  "complete  division  of  each  lateral  third  of  the 
tendon  and  careful  snipping  of  the  superficial  fibers  in  the  central  third, 
until  sufficient  elongation  is  obtained  to  yield  a  measurement  of  ortho- 
phoria." 


Fig.  388. 


Figs.  389-391. 
Figs.  380-391. — Stevens'  iiistniiiicnts  for  tenotomy. 

Advancement  or  readjustment  is  an  operation  in  which  the 
tendon  of  a  rectus  musele  is  brought  forwartl  to  a  new  attachuKMit. 
The  operation  is  api)lical)le  to  cases  in  which  tlu>  tendon  has  become 
weakened,  as,  for  instance,  in  myopia,  together  with  the  proiluction  of 
divergent  squint;  to  those  cases  of  convergent  strabismus  in  which  it  is 
desirable  to  combine  advancement  of  the  external  rectus  with  tenotomy 
of  the  internus;  to  free  l)ilaleral  advancement  to  the  exclusion  of  tenot- 
omy; to  certain  cases  of  hc^teroijhoria  (^see  i)age  010);  ami  to  cast>s  in 
which  an  injudicious  division  of  the  internal  rectus,  for  instance,  has 
converted  a  conv(Mgent  inlo  adivergent  squint.  For  other  indications, 
see  pages  000  and  007.  (Jeneral  anesthesia  may  be  necessary  in  young 
subjects  and  nervous  patients. 


ADVANCEMENT    OE    EEADJUSTMENT  751 

The  same  instruments  which  are  used  in  tenotomy  are  required,  in 
addition  to  which  suitable  curved  needles,  a  needle-holder,  silk  thread, 
fine  catgut,  and  advancement  forceps  should  be  provided.  Numerous 
methods  of  advancement  have  been  designed.  It  is  possible  only  to 
record  in  detail  a  few  standard  operations  and  to  make  reference  to 
others  that  have  proved  their  value.  With  the  operation,  a  description 
of  which  follows,  recommended  by  Swanzy,  the  author  has  achieved 
satisfactory  results: 

An  opening  is  made  in  the  conjunctiva  immediately  over  the  insertion  of  the 
tendon  which  is  to  be  advanced,  twice  the  breadth  of  the  tendon.  A  band  of  con- 
junctiva between  the  opening  and  the  cornea  is  next  separated  with  the  scissors 
from  the  sclera.  A  strabismus  hook  is  now  passed  under  the  tendon,  which  is 
freely  separated  from  the  sclera;  the  hook  is  brought  well  up  to  the  insertion  of  the 
tendon,  care  being  taken  that  the  whole  width  of  the  tendon  is  held  on  the  hook.  A 
curved  needle  carrying  a  strong  black  silk  suture  is  introduced  from  its  upper  mar- 
gin between  the  muscle  and  sclera,  and  passed  through  the  muscle  at  its  middle 
line.  In  the  same  way  another  suture  is  passed  behind  the  muscle  from  its  lower 
margin,  and  through  it  close  to  the  first  suture.  Each  of  these  sutures  is  knotted 
firmly  on  the  muscle,  a  long  end  being  left  to  each.  For  the  strabismus  hook 
Prince's  advancement  forceps  is  now  substituted,  which  firmly  grasps  the  tendon, 
which  is  next  separated  with  scissors  from  the  sclera  close  to  its  insertion.  The 
needle  on  the  end  of  each  suture  is  next  passed  through  the  superficial  layers  of  the 
sclera  and  beneath  the  conjunctival  flap  to  the  margin  of  the  cornea  in  the  manner 
illustrated  in  Fig.  393,  and  while  an  assistant  rotates  the  eyeball  toward  the  muscle 
which  is  to  be  advanced,  each  suture  is  tied  with  its  own  end.  If  there  is  redundant 
tissue,  it  is  trimmed  away  and  the  conjunctiva  sewed  with  three  interrupted 
sutures  over  the  advanced  tendon,  the  central  suture  being  passed  through  the 
conjunctiva  and  the  advanced  tendon  to  the  margin  of  the  cornea.  .  Naturally,  a 
greater  or  less  effect  is  produced  according  as  the  sutures  are  placed  farther  from 
or  nearer  to  the  insertion  of  the  tendon,  and  according  to  the  extent  to  which  the 
loosened  tendon  is  drawn  toward  the  corneal  margin.  Both  eyes  are  bandaged  and 
should  remain  covered  for  at  least  four  days,  when  the  superficial  sutures  are 
removed.  The  deep  sutures  are  allowed  to  remain,  if  they  produce  no  irritation, 
from  eight  to  ten  days.  An  objection  to  this  operation  is  the  knot  in  the  tendon, 
which  must  be  removed  through  a  small  opening  in  the  conjunctival  surface,  but 
if  black  silk  is  used  the  author  has  not  experienced  any  difficulty;  and  it  has 
seemed  to  him  that  the  results  were  better  than  if  the  suture  was  not  fastened  in 
the  manner  described. 

Landolt's  Method  of  Aduancement. — "The  speculum  having  been  adjusted,  a  con- 
junctival flap  the  summit  of  which  reaches  the  edge  of  the  cornea  is  cut  and  folded 
back  so  as  to  expose  the  insertion  of  the  muscle  which  is  to  be  advanced.  Next  a 
flattened  hook  is  passed  beneath  the  tendon  and  a  second  one  in  the  opposite  direc- 
tion. The  first  hook  is  then  withdrawn  and  the  second  intrusted  to  an  assistant. . 
Two  sutures  are  now  introduced  from  without  inward,  about  one-third  of  the  width 
of  the  muscle  from  either  edge.  These  sutures  also  include  the  surrounding  tissues. 
In  simple  advancement  the  sutures  are  introduced  immediately  behind  the  hook, 
and  the  insertion  of  the  muscle  is  detached  from  the  ocular  globe.  In  a  resection 
the  sutures  are  introduced  further  back  and  the  muscle  divided  between  them  and 
the  hook.  In  order  to  accomplish  this  the  muscle  is  gently  raised — at  one  part  by 
means  of  the  four  ends  of  the  stitches,  which  the  surgeon  holds  in  his  left  hand,  and 
at  the  other  by  the  hook  which  the  assistant  holds — and  the  tendinous  end  sepa- 
rated from  the  eyeball.  One  of  the  needles  is  next  passed  above,  and  the  other 
below,  the  meridian,  into  the  episcleral  tissue  close  to  the  corneal  margin  (a-b, 
Fig.  394),  to  the  extent  of  several  millimeters.  If  the  needle  does  not  penetrate 
sufficiently  deep,  it  should  be  guided  farther  underneath  the  conjunctiva,  and  if  it  is 


752 


OPERATIONS 


feared  that  it  has  not  a  thorough  grasp,  it  may  be  passed  once  more  through  the 
conjunctiva.  The  assistant  now  seizes  the  ocular  globe  with  a  fixation  forceps  at 
the  level  of  the  antagonistic  muscle,  and  rotates  it  toward  the  muscle  which  is  to 
be  advanced,  while  the  surgeon  ties  the  sutures,  one  of  which  is  composed  of  white 
silk  and  the  other  of  black  silk.  Both  eyes  are  bandaged  for  five  days  in  divergent, 
and  for  a  week  in  convergent,  strabismus.  The  sutures  are  u.sually  remoTcd  on 
the  sixth  dav.'' 


Fig.  392. — Advancement  of  the  external  rectus.     The  muscle  has  been  exposed  and  the 

sutures  tied  upon  it. 

In  A.  E.  Prince's  method  of  advancement  an  unyielding  fixation 
point  is  obtained  by  utilizing  the  dense  episcleral  tissue,  severing  the 
muscle,  and  regulating  the  effect  by  a  "pullej'  suture"  (Fig.  385). 
In  Schweigger's  method  a  free  exposure  of  the  muscle  is  made,  and 


Fig.  39.'J. — .VdvuiicenuMit  of  tlie  external  rectus.  Tlie  tetiilon  ha.s  heen  sei>ar!itod 
from  its  scleral  attaclinieat,  and  the  sutures  will  l»e  passed  throuKli  the  scleral  tiMUo 
beneath  the  conjunctiva  in  tlie  direction  of  the  Itroken  line. 

after  the  teruion  is  divided  a  portion  of  the  end  is  resected;  catgut 
sutures  an;  enij)loyed  to  advance  the  muscle  (see  Hi'esf's  operation, 
page  754).  II.  I).  Bruns,  of  New  Orleans,  has  described  :in  ingenious 
operati(»n  for  advaiicerMcnl   of  (he  recti  tendons,  performed  with  the 


I, 


ADVANCEMENT    OR    READJUSTMENT 


753 


aid  of  a  Clark  hook  and  the  formation  of  a  tuck  in  the  tendon,  which  is 
firmly  flattened  down  and  drawn  strongly  forward,  and  held  in  place 
by  a  combination  of  pulley  and  guy  suture.^ 

Todd,  after  exposing  a  considerable  portion  of  the  tendon  by  means 
of  a  flap  incision  through  the  conjunctiva  and  capsule,  formed,  with  the 
aid  of  an  instrument  known  as  the  tendon  folder,  an  actual  folding,  and. 
fixated  the  duplicature  with  catgut  sutures  reinforced  with  silk  sutures,, 
which  included  the  conjunctival  flap.  Greenwood  performs  a  com- 
bined tucking  and  advancement  in  that  after  exposure  of  the  muscle 
an  ordinary  tuck  is  made  and  a  suture  passed  through  each  corner  of 
the  top  of  the  tuck  and  next  through  the  episcleral  tissue  in  such  a 
manner  that  the  tuck  is  fastened  down  to  the  sclera  well  forward. 


Fig.  394  . — Landolt's  method  of  advancement. 


Finally,  the  conjuctiva  is  sutured  over  the  muscle  thus  tucked 
and  advanced.  R.  O'Connor  has  designed  an  ingenious  and  new 
operative  procedure  for  shortening  and  lengthening  ocular  muscles.^ 
In  Worth's  method  of  advancement  the  needles  carrying  the  sutures 
pass  through  the  conjunctiva,  capsule,  and  muscle.  The  main  sutures 
ultimately  are  passed  through  the  sclera,  the  needles  traversing  at  least 
one-half  the  thickness  of  the  sclera.^  Meyer  Wiener  in  his  advancement 
operation  ties  the  sutures  over  flat  metal  (gold)  plates  on  the  same 
principle  as  the  tension  sutures  used  in  harelip  operations.''  Lancaster 
exposes  the  muscle  to  be  advanced  by  a  straight  longitudinal  incision 

^  For  the  method  of  performing  this  operation,  see  Ophthalmic  Record,  June,  1903. 

2  For  the  method  of  operating,  see  Ophthalmic  Record,  December,   1914. 

3  For  the  method  of  operating,  see  Squint :  its  Causes,  Pathology,  and  Treat- 
ment, 4th  edition,  by  Claud  Worth. 

*  Transaction  of  the  American  Academy  of  Ophthalmology  and  Otolaryngology 
1919. 

48 


754 


OPERATIONS 


from  near  the  cornea  to  near  the  canthus;  a  longitudinal  incision  is 
also  made  in  the  capsule.  The  muscle  sutures  are  in  the  form  of  a 
whip  stitch  enforced  b}'  a  security  stitch.^ 

Of  the  methods  of  advancement  which  have  been  recorded,  the 
author  is  in  the  habit  of  employing  the  one  which  is  described  first  and 
Landolt's  procedure;  he  also  finds  Worth's  operation  exceedingly 
valuable. 

Reese's  Muscle=resection  Operation. — Dr.  Robert  G.  Reese 
operates  as  follows,  the  description  of  the  operation  being  in  his  own 
words : 


Fig.  395. — Reese's  forceps  for  operation  in  squint. 

For  the  external  and  internal  rectus  make  a  vertical  incision  in  the  conjundioa 
6  mm.  from  the  corneoscleral  margin,  commencing  at  the  level  of  the  upper  corneal 
border,  and  extending  to  the  horizontal  plane  of  the  lower  border. 

At  the  upper  and  lower  limits  of  the  incision  just  made  grasp  the  tissue  anterior 
to  the  sclera  with  forceps  and  open  with  scissors,  directing  their  point  away  from 
the  muscle.  This  procedure  allows  the  passage  of  the  strabismus  hook  under  the 
entire  muscle. 

When  the  muscle  is  held  on  the  hook,  dissect  all  the  conjunctival  and  subcon- 
junctival tissue  back  to  the  canthus,  exposing  the  bare  muscle  completely. 


FiQ.  396. — Passage  of  the  strabismus  hook  under  tlic  entire  muscle  (Ueesc). 


The  lateral  mvaginations  of  Tenon's  capsule,  which  are  attached  to  the  tendons 
of  the  ocular  muscles,  must  be  dis.sected  free  and  clear. 

One  blade  of  the  resection  forceps  is  tlien  inserted  beneath  tlie  muscle  at  a  right 
angle  to  its  course,  so  that  the  groove  on  the  blade  lies  directly  over  the  middle 
fibers  of  the  niu.scle.  Clamp  the  forceps  to  the  last  notch,  and  do  not  let  its  grasp 
include  anything  but  muscle. 

Sever  the  muscle  2  mm.  from  its  scleral  attachment,  leaving  a  stump,  so  that  the 
resected  end  can  be  sewed  to  its  original  insertion.  Tree  the  belly  of  the  niu.scle 
from  any  scleral  adhesions.     Three  sutures  are  necessary. 

Put  tlie  sutures  in,  commencuig  with  the  middle,  which  is  a  No.  3  braided  silk 
with  a  needle  on  each  end.     Pass  one  neeiile  through  the  scleral  surface  of  the  muscle 

1  American  .Fi)uriial  of   Oplilhaltuology,    March,    191S.      \\'A\  illustrated. 


REESE  S     MUSCLE-RESECTION     OPERATION 


755 


posterior  to  the  blade  of  the  forceps  and  4  mm.  back  of  the  point  of  resection,  and 
1  mm.  to  the  side  of  the  groove  on  the  forceps;  then  pass  the  other  needle  the  same 
way,  but  to  the  other  side  of  the  groove,  making  a  loop  with  the  suture  on  the 
scleral  surface  of  the  muscle.  As  the  needles  pierce  the  muscle,  let  them  include 
the  dissected  edge  of  subconjunctival  and  conjunctival  tissues. 


Fig.  397. — Showing  the  three  necessarj'  sutures  (Reese). 

The  two  wing  sutures  are  No.  5  silk  with  a  single  needle  passed  first  through  the 
upper  and  lower  part  of  the  dissected  conjunctiva  and  episcleral  tissues,  including 
the  superior  and  inferior  border  of  the  muscle,  and  slightly  posterior  to  the  loop 
made  by  the  middle  suture. 


Fig.  398. — Showing  the  muscle  resected  and  sutures  in  scleral  stump  (Reese) . 


loop. 


Cut  the  muscle  anterior  to  the  sutures,  leaving  at  least  2  mm.  in  front  of  the 


Insert  the  two  needles  attached  to  the  middle  suture  2  mm.  apart,  through  the 


756  OPERATIONS 

center,  and  the  other  two  neecHes  through  the  upper  and  lower  edges  of  the  scleral 
stump.  These  needles  should  include  the  conjunctiva  as  they  pass  from  behind 
forward. 

Tie  the  middle  suture  first  in  a  loop,  and  do  not  use  a  surgeon's  knot,  as  it  will 
not  pull  up  well.  The  lateral  sutures  are  next  tied.  No  supplementary'  conjunc- 
tival sutures  are  necessary. 

The  middle  suture  is  removed  in  ten  days,  and  the  others  can  be  taken  out  any 
time  after  forty-eiRht  hours,  or  if  left  in  they  soon  fall  out. 

The  eye  operated  upon  only  is  bandaged  and  is  dressed  daily  for  five  days,  when 
boric  acid  bathing,  three  times  a  day,  i.s  ordered;  and  if  the  eye  is  not  overcorrected, 
the  correcting  lenses  are  ordered  for  constant  use.  On  the  other  hand,  if  there  is  an 
undercorrection,  a  mydriatic  is  used  and  the  proper  glass  is  worn  constantly. 

The  operation  consists  in  resecting  the  muscle  only,  and  not  cutting  out  anj'  of 
the  other  tissues  of  the  eje.  It  is  a  myectomy,  because  in  no  degree  of  squint,  how- 
ever slight,  will  removing  the  tendinous  portion  of  the  muscle  be  sufficient. 

Operation  for  Shortening  the  Tendon. — G.  C.  Savage  and 
Francis  Valk  secure  the  advantages  of  advancement  by  an  operation 
in  which  the  tendon  is  shortened.  The  last-named  surgeon  operated 
as  follows : 

"The  conjunctiva  is  raised  with  forceps  over  the  lower  or  upper  point  of  the 
insertion  of  the  tendon,  and  a  vertical  incision  followed  by  a  horizontal  one,  forming 
an  L,  is  made.  This  is  dissected  loose  from  the  underljing  tissue,  and  then  an 
opening  is  made  in  Tenon's  capsule  and  a  small  hook  is  passed  beneath  the  tendon. 
As  the  point  of  the  hook  comes  out,  another  hook  is  inserted  in  an  opposite  direc- 
tion, and  the  two  hooks  forcibly  drawn  apart,  thus  exposing  the  tendon  and  part  of 
the  muscle.  Next  a  small  instrument  called  a  twin  strabismus  hook  is  passed 
beneath  the  muscle,  and  the  hooks  are  allowed  to  separate  by  the  action  of  a  small 
spring  in  the  joint,  and  the  two  hooks  are  then  removed.  The  muscle  and  the 
tendon  are  now  fully  exposed  and  ready  for  the  suture.  A  needle  threaded  with 
catgut  is  passed  first  through  the  lower  part  of  the  tendon,  then  through  the  muscle 
as  far  backward  as  it  is  desired  to  make  the  'tuck,'  passing  from  within  outward. 
It  then  goes  across  the  belly  of  the  muscle  and  is  passed  through,  from  without 
inward  and  back  to  the  tendon,  where  it  passes  from  within  outward,  at  a  point 
corresponding  to  its  first  insertion.  As  the  ends  are  tied  over  the  tendon  at  this 
point  it  is  easy  to  see  the  'tuck'  formed  as  the  muscle-belly  is  drawn  forward  and  its 
long  axis  shortened." 

Advancement  of  the  capsule  of  Tenon  is  recommended  by  some 

surgeons.  S.  Lewis  Ziegler  has  designed  a  capsuJo77ivscuInr  advance- 
ment u-ith  partial  resection.     His  method  is  as  follow?: 

A  vertical  incision  is  made  in  the  conjunctiva  near  the  linibus  and  tlio  tendon 
and  muscle  raised  on  two  tenotomy  hooks  introduced  fron\  below  upward  and  put 
slightly  on  a  stretch.  One  arm  of  a  double  armed  suture  is  then  inserted  through 
the  lower  edge  of  the  muscle  from  before  backward  and  the  same  suture  repeated 
behind  the  first,  thus  making  a  marginal  whip-stitch.  The  thread  is  then  pas-sed 
partly  acro.ss  the  top  of  the  muscle  and  a  similar  double  stitch  is  duplicated  on  the 
upper  margin  of  the  muscle. 

Kacli  needle  is  now  carried  backward  in  a  parallel  line  beneath  Tenon's  capsule 
and  made  to  emerge  on  the  conjunct  ival  surface.  A  small  wedge  or  V-shaped  piece 
is  then  cut  away  from  each  peripheral  third  of  the  muscle,  above  and  below,  with 
punch  or  scissors,  leaving  a  central  strand  of  fibers  intact. 

The  needles  are  now  entered  through  the  conjunctiva  at  the  upper  ami  lower 
extremities  of  the  wound,  passed  firmly  into  the  sclera  for  solid  anchorage,  and 
brought  out  near  the  limbus,  where  the  suture  is  tieil  jifter  the  toilet  of  the  wound 


INTRODUCTION    OF    THE    LACRIMAL    PROBE 


757 


has  been  performed.  This  leaves  a  knot  and  two  parallel  lines  of  thread  exposed 
on  the  conjunctival  surface,  thus  holding  all  the  tissue  flat  against  the  sclera.  The 
good  judgment  of  the  operator  must  decide  how  much  capsule  shall  be  engaged  and 
just  how  tight  the  graduated  suture  shall  be  drawn.  As  a  rule,  the  squint  should 
be  slightly  overcorrected.  If  indicated,  certain  measures  should  also  be  taken  to 
weaken  the  pull  of  the  antagonist. 

OPERATIONS  UPON  THE  LACRIMAL  APPARATUS 

Slitting  the  Canaliculus. — This  is  performed  as  follows: 
The  lid  being  drawn  down  and  out  with  the  thumb,  and  the  canaliculus  knife 
held  vertically,  the  probe  point  is  introduced  into  the  punctum.     The  handle  is  now 


Fig.  399. — Weber's  canaliculus  knife. 

depressed  into  the  horizontal  position,  and  the  instrument  pushed  along  the  canal 
until  the  probe  point  touches  the  inner  wall  of  the  lacrimal  sac.  It  is  then  raised  to 
the  vertical  line  with  the  cutting  blade  turned  slightly  inward,  and  the  roof  of  the 
canaliculus  divided.     Either  the  upper  or  the  lower  canaliculus  may  be  slit. 


Fig.  400. — Introduction  of  a  lacrimal  probe  (Meyer). 

Introduction  of  the  Lacrimal  Probe. — The  probe  (Bowman's  or 
Williams'  probes  are  commonly  employed ;  modifications  have  been  de- 
vised by  Theobald  and  Tansley)  is  introduced  by  passing  it  hori- 
zontally along  the  canahculus  until  its  point  touches  the  lacrimal  bone. 
It  is  raised  to  the  vertical  position  and  pushed  into  the  duct,  remem- 
bering that  the  direction  should  be  downward,  shghtly  backward,  and 
usually  outward.  Ziegler  performs  rapid  dilatation  of  the  lacrimo- 
nasal  duct  with  a  specially  devised  dilator. 


758 


OPERATIONS 


Incision  of  a  Stricture. — If  the  stricture  resists,  it  may  be  divided 
with  a  knife,  either  the  one  which  has  been  employed  in  sHtting  the 
canaUculus  or,  still  better,  with  the  instrument  of  Stilling.  The  knife 
is  introduced  in  the  same  way  as  the  probe,  pushed  down  into  the  duct, 
and  the  stricture  incised.  The  knife  is  next  partially  withdrawn, 
turned  slightly,  and  the  maneuver  repeated.  Dr.  Charles  Hermon 
Thomas  has  devised  a  special  knife,  or  siricturotome,  which  may  be 
utilized  for  this  purpose. 


Fig.  401. — Lacrimal  probes. 

Introduction  of  the  Lacrimal  Syringe. — The  nozzle  of  an  Anel 
syringe  can  be  introduced  along  the  canaliculus  without  slitting  it. 
The  lid  is  drawn  down  and  outward  in  the  same  manner  as  if  the 
operation  of  slitting  the  canaliculus  were  to  be  performed,  and  the 
point  of  the  syringe  introduced.  Sometimes  the  punctum  is  swollen 
shut  and  the  nozzle  cannot  be  inserted.  In  these  circumstances  the 
punctum  may  be  dilated  with  a  silver  pin.  Ordinarily  a  lacrimal 
syringe  is  furnished  with  a  cannula  probe.  This  is  introduced  into 
the  duct  in  precisely  the  same  manner  as  the  solid  probe;  the  syringe 
is  filled  with  an  antiseptic  fluid,  inserted  into  the  mouth  of  the  cannula, 
and  the  liquid  injected  into  the  duct. 


Fig.  402. — Thomas'  stricturotome. 

Curettage  in  Dacryocystitis. — W.  K.  Thomi)son  in  the  treatment 
of  dacryocystitis  slits  the  canaliculus,  introduces  a  small  sharp  curet 
with  which  the  sac  or  the  duct,  or  both,  according  to  the  condition, 
are  carefully  but  thoroughly  curetted.  Following  this  a  25  percent, 
solution  of  iodin  is  applied  to  the  inner  walls  of  the  sac  and  duct. 
John  Green,  Jr.,  after  freely  slitting  the  canaliculus  performs  rapid 
dilatation  of  the  lacrimonasal  duct  with  a  Theobald  probe  (No.  5  or 
6)  and  follows  this  by  curettage  according  to  the  method  of  Thompson. 
These  surgeons  report  satisfactory  results.  With  their  technic  the 
author  has  had  no  i)ractical  experience. 

Excision  of  the  Lacrimal  Sac-  In  order  to  meet  the  iiuhcations 
descril)e(l  on  page  029,  excision  of  the  lacrimal  sac  may  be  performed  as 
follows : 


EXCISION     OP    THE    LACRIMAL    SAC 


759 


After  thorough  cleansing  of  the  sac  through  the  canahculus  with  a  1  :  10,000 
bichlorid  of  mercury  solution,  general  anesthesia  may  be  induced,  although  in  most 
instances  careful  local  anesthesia  will  be  sufficient  (see  page  658).  With  the  skin 
drawn  toward  the  bridge  of  the  nose,  the  surgeon  makes  a  slightly  curved  incision 
down  to  the  periosteum,  which  extends  from  4  mm.  above  the  internal  palpebral 
ligament  to  5  mm.  below  it,  its  length  being  2)4  cm.  The  canthal  ligament  may  or 
may  not  be  divided  with  scissors,  and  while  the  lips  of  the  wound  are  separated,  the 


Fig.  403. — Anel  syringe. 

temporal  lip  being  especially  drawn  outward,  the  fibrous  expansion  from  the  tendo 
oculi  is  divided  through  its  whole  length,  exposing  the  sac,  which  usually  can  be 
recognized  by  its  bluish  color.  The  sac  is  next  gradually  separated  from  the  perios- 
teum, being  dissected  out  very  much  in  the  manner  of  removing  a  cyst,  care  being 
taken  not  to  rupture  its  walls.  The  internal  surface,  the  upper  end  and  the 
posterior  surface  of  the  sac  having  been  freed,  is  cut  through  at  the  commencement 
of  the  nasal  duct.     Sometimes  the  field  of  observation  is  obscured  by  a  smart 


Fig.  404. — Extirpation  of  the  lacrimal  sac  (Haab). 

hemorrhage,  which  usually  can  be  controlled  by  pressure  or  by  specially  devised 
specula;  for  example,  those  introduced  by  Axenfeld,  or  even  more  satisfactorily 
with  the  retractor  designed  by  Bishop  Harman.  Should  the  operator  experience 
any  difficulty  in  outlining  the  sac,  its  position  may  be  localized  by  inserting  a 
strabismus  hook  through  the  canaliculus  into  the  sac  and  keeping  it  there  during 
the  operation.     This  method  was  introduced  by  E.  A.  Shumway,  and  is  most 


760 


OPERATIONS 


satisfactorj-  in  practice.  Some  surKCons  advise  that  the  sac  shall  be  filled  with 
melted  paraffin  prior  to  the  operation,  a  procedure  which  the  author  has  never 
found  to  be  necessary'. 

C.  R.  Holmes  did  not  believe  that  division  of  the  tendo  oculi  is  required  in  order 
to  expose  the  sac,  but  dissected  out  the  sac  from  underneath  the  tendon.  If  the 
tendo  oculi  has  been  severed,  it  may  be  replaced  or  repaired  by  a  strong  suture. 
Great  care  must  be  taken  that  every  portion  of  the  sac  is  removed,  and  the  opera- 
tion may  be  terminated  by  thoroughly  ciireting  the  region  (which  usually  is 
unnecessarj'  if  the  technic  has  been  correct)  and  the  ductus  ad  nasum,  removing  all 
traces  of  mucous  membrane.  Two  sutures  close  the  wound,  which  usually  heals 
promptl}'.  Holmes  advi.ses  that  the  canaliculi  should  also  be  destroyed.  Other- 
wise a  blind  pocket  forms  at  the  inner  canthus.  In  order  to  accomplish  this  he 
splits  the  canaliculi  through  their  entire  length  and  destroys  their  lining  membrane 


iadi 


Fig.  40.J. — Excised  lacrimal  sac.  I)eii.se  infiltration  of  mucosa  with  round  celie; 
erosion  and  degeneration  of  the  epithelium;  sac  wall  densely  fibroua'and  vessels  en- 
gorged.     Insane  patient  (Philadelphia  r.cMeral  HospilaO. 

with  the  actual  cautery.  Tiie  ilressing  sliuuUl  ron.sist  of  a  pressure  bandage  placeil 
over  a  light  compress.  There  are  many  modifications  of  the  operation  of  excision 
of  tlie  lacrimal  sac.     The  most  elaborate  technic  is  the  one  tlevised  by  Meller.' 

Extirpation  of  the  Lacrimal  Gland. — Following  the  direct  ion  of 
C.  R.  Holmes,  this  may  be  performed  as  follows: 

An  incision  beginning  near  the  center  of  the  upper  orbital  arch  and  following  the 
bony  margin  is  carried  to  a  point  3  mm.  below  the  outer  canthus.  Next  the  fsiscia 
or  septum  orbitale  is  cut  through  along  its  attachment  to  the  orbital  margin. 
Should  f.itty  tissue  present  in  the  wound,  it  must  be  held  to  one  .side  with  retractors 
and  all  bleeding  from  the  edge  of  the-  wound  must  be  controileil  before  the  gland  is 
separated  from  its  surroundings,  inasmuch  lus  it  is  sometimes  very  difficult  to 
distinguisli  the  gland  from  the  surrounding  fatty  tissue,     liy  means  of  blunt- 

'  "OpIitliMhnic  Surgery"  Tr.-uislation  edited  1)\   W.  M.  Sweet. 


mosher's  operation  761 

pointed  scissors,  fixation  forceps,  a  small  knife,  and  tenotomy  hooks  the  dissection 
of  the  gland  can  be  accomplished,  and  it  may  be  removed  without  leaving  any 
portion  of  it  behind.  Before  the  wound  is  closed  all  bleeding  nmst  be  stopped. 
The  lips  of  the  wound  are  united  with  interrupted  silk  sutures,  and  the  usual  anti- 
septic dressing  applied.  As  complications,  hemorrhage  into  the  orbit  and  atrophy 
of  the  optic  nerve  have  been  reported,  and  on  a  number  of  occasions  a  persisting 
conjunctivitis,  and  also,  as,  for  example,  in  Veasey's  case,  a  form  of  keratitis. 

Extirpation  of  the  Palpebral  Portion  of  the  Lacrimal  Gland. 

Instead  of  the  removal  of  the  orbital  lacrimal  gland,  extirpation  of 
the  palpebral  gland  is  often  practised.  It  is  a  much  simpler  operation 
and  may  be  performed  as  follows : 

Thorough  local  anesthesia  having  been  secured,  the  upper  lid  is  everted  and 
drawn  upward  from  the  eyeball  while  the  patient  looks  strongly  downward.  This 
exposes  the  palpebral  gland,  which  may  be  seized  with  toothed  forceps  and  drawn 
outward.  Its  conjunctival  covering  is  next  incised,  and  the  gland  dissected  from  its 
surroundings.  Hemorrhage  having  been  controlled,  the  wound  may  be  closed  with 
one  or  two  interrupted  silk  or  catgut  sutures,  the  upper  lid  replaced,  and  a  light 
pressure  bandage  applied.     The  stitches  are  removed  on  the  third  daj-. 

Toti's  Operation  {Dacryocystorhinostomia). — -In  this  operation  a 
passageway  for  the  tears  is  made  through  the  bony  wall  of  the  nose,  and 
its  main  points  are  briefly  summarized  by  Torok,  who  recommends  it  as 
a  valuable  procedure,  as  follows:  After  chiselling  through  the  bony 
lacrimal  fossa,  the  internal  wall  of  the  lacrimal  sac  is  resected,  and  at  the 
same  time  a  part  of  the  mucous  membrane  of  the  nose  is  removed,  which 
is  of  approximately  the  same  size  as  the  remaining  external  wall  of  the 
sac.  The  edges  of  the  two  mucous  membranes  are  now  brought  into 
close  connection,  so  as  to  permit  their  growing  together.  The  mucous 
membrane  of  the  lacrimal  sac  takes  the  place  of  the  removed  nasal 
mucous  membrane.  Together  they  now  form  one  continuous  mucous 
membrane,  and  with  that  the  closing  of  the  defect  is  prevented.  The 
author  has  had  no  experience  with  this  operation. 

West's  Operation  {Window  Resection  of  the  Nasal  Duct  in  Stenosis). 
— This  consists  in  resecting,  under  local  anesthesia,  a  window  from  the 
nasal  duct  in  the  upper  part  of  the  nose  above  the  inferior  turbinate, 
and  involves  the  removal  of  part  of  the  lacrimal  bone  and  also  a  piece 
from  the  superior  maxilla.  This  removes  a  stricture  in  the  upper  part 
of  the  duct,  but  leaves  a  stenosis  in  the  lower  part  untouched.  It  is, 
according  to  J.  M.  West,  who  has  designed  this  operation  and  whose 
description  is  quoted,  immaterial  whether  the  lower  part  of  the  duct  is 
stenosed,  so  long  as  the  tears  can  drain  through  the  artificial  window. 
Previous  to  operation  a  probe  is  passed  into  the  duct  to  act  as  a  guide. 

Mosher's  Operation. — This  is  an  operation  devised  for  the 
purpose  of  draining  the  lacrimal  sac  and  the  nasal  duct  into  the  unci- 
form fossa.     Mosher  summarizes  the  technic  as  follows : 

"The  essential  steps  of  the  operation  are  the  uncovering  of  the  unciform  fossa 
by  the  removal  of  the  anterior  end  of  the  middle  turbinate,  and  the  dissection  of  a 
mucous  membrane  and  periosteal  flap  from  the  fossa;  the  breaking  down  of  the 
inner  wall  of  the  unciform  cell  and  the  slitting  of  the  inner  wall  of  the  nasal  duct 


762 


OPERATIONS 


and  lacrimal  sac,  and  the  widening  of  the  nasal  duct  by  removing  the  lip  of  the 
ascending  process  of  the  superior  maxilla.  The  thing  to  avoid  is  opening  the 
unciform  groove  and  establishing  an  accessory  ostium  of  the  antrum  which,  from  its 
position,  would  carry  infection  from  the  lacrimal  sac  into  the  cavity  of  the  sinus. 
Like  all  other  operations  on  the  lacrimal  canal,  it  faces  the  danger  of  cicatricial 
closure  of  the  canal  and  the  necessity  of  reslitting  the  duct  and  the  sac;  but  unlike 
the  other  measures  it  gives  a  much  larger  opening  of  the  lacrimal  sac  and  the 
nasal  duct.  Should  reslitting  of  the  canal  become  necessary,  it  is  easih'  ex- 
ecuted under  direct  vision.  The  operation  has  the  advantage  that  the  manipula- 
tions are  carried  out  in  thin  bone  and  toward  an  absolute  anatomic  landmark."' 
With  endonasal  operations  for  the  rehef  of  chronic  dacryocystitis 
the  author  has  no  practical  experience.  The  results  from  excision  of 
the  sac  are  satisfactory.  The  resulting  epiphora  usually  subsides  mate- 
rially because  of  the  elimination  of  the  irritating  influence  of  purulent 
secretion,  sometimes  it  disappears  entirely. 

'The  treatment  of  chronic  dacryocystitis  from  the  standpoint  of  intranasal 
drainage  has  been  discussed  by  a  number  of  other  surgeons  and  various  additional 
operations  have  been  designed.  Consult:  J.  V.  Patterson  and  J.  S.  Frazer,  Brit. 
Journ.  Ophthal.,  iii,  1919.  Yaukauer,  The  Laryngoscope,  x.xii,  1912.  W.  L. 
Benedict  and  R.  A.  Barlow,  Amer.  Journ.  Opthal.,  Vol.  ii,  1919. 


APPENDIX 

The  Use  of  the  Ophthalmometer. — Ophthalmometry  or,  more 
properly,  keratometry  has  been  briefly  referred  to  on  page  116.  A 
number  of  new  models  of  the  Javal-Schiotz  ophthalmometer  are  now 
obtainable,  with  variations  in  the  disk,  form  of  arm,  and  method  of 
illumination,  but  they  do  not  introduce  radical  changes.  The  fol- 
lowing rules,  prepared  by  the  late  Dr.  E.  W.  Stevens,  formerly  asso- 


FiQ.  406. — Javal-Schiotz  ophthalmometer  (old  model). 

ciated  with  the  author  in  the  Philadelphia  Polyclinic,  (now  the  Poly- 
clinic Section  of  the  Graduate  School  of  Medicine  of  the  University 
of  Pennsylvania)  will  enable  the  student  to  understand  the  proper 
method  of  using  this  instrument,  as  it  is  illustrated  in  Fig.  406,  as 
well  as,  in  general  terms,  of  the  modern  models. 

The  examiner,  after  satisfying  himself  that  the  illumination  from  the  electric 
bulb  is  accurate,  should  carefully  adjust  the  telescope  by  looking  through  it  and 
turning  the  eye-piece  either  to  the  right  or  the  left  until  the  cross-hairs  are  brought 
clearly  into  view.  The  telescope  is  then  turned  so  that  the  long  pointer  is  below 
and  at  zero.  .  The  stationary  mire  on  the  parallelogram  (Fig.  407,  A)  should  be  ex- 
amined to  see  that  it  is  in  proper  position,  which  is  at  20°  on  the  graduated  arc. 

The  patient  is  now  seated  before  the  instrument  in  an  easy  position,  with  his 
chin  resting  on  the  chin-rest  and  his  forehead  pressed  against  the  forehead-rest. 
His  eyes  should  be  widely  opened  and  exactly  horizontal — points  to  be  determined 
bj'  sighting  through  the  transverse  slit  above  the  telescope.  One  eye  is  now  covered 
with  a  small  shade,  and  the  observer  sights  along  the  telescope,  through  the 
notch  above  it,  at  the  patient's  eyebrow;  then,  sighting  through  the  tube,  he  moves 

763 


764 


APPENDIX 


the  instrument  forward  or  backward  and  raises  or  lowers  it  by  tlie  thumb-screw 
until  the  eye  is  brought  into  the  field  of  the  telescope,  and  a  distinct  image  of  the 
disk  and  mires  is  seen  on  the  cornea. 

The  images  of  the  disk  are  doubled,  and,  overlapping  each  other,  form  an  oval 
space  in  which  are  seen  the  two  mires  or  targets,  to  which  the  beginner  should 
confine  his  attention.  The  observer  now  slides  the  mire  at  his  right  along  the  arc 
until  its  reflection  touches  the  reflection  of  the  stationary  mire,  and  notes  whether 
the  two  lines  bisecting  the  two  mires  are  continuous.  If  these  two  lines  are  not 
continuous,  the  telescope  is  turned  so  that  the  long  pointer  will  move  from  0° 
toward  13o°.  If  the  transverse  lines  do  not  become  continuous  when  135°  is 
reached,  the  rotation  proceeds  no  farther  in  this  direction,  but  the  long  pointer  is 
turned  back  to  0°  and  then  toward  45°,  but  never  beyond  45°.  With  regular 
astigmatism  the  lines  always  become  continuous  within  45°  of  0°.  ^\'hen  the  lines 
are  continuous  the  mires  must  be  brought  into  perfect  appro.vimation  (Tig.  407,  1). 
This  is  the  primary  position,  which  should  be  carefully  recorded  according  to  the 
position  of  the  long  pointer. 

The  telescope  is  next  turned  so  that  the  long  pointer  moves  90°  to  the  left  of  the 
primary  position — i.  c,  to  a  point  which  is  known  as  the  second  position. 


Fig.  407. — The  mires. 


If  the  mires  overlap  (Fig.  407,  3) — for  example,  two  steps  in  the  second  position 
with  the  long  pointer  at  90° — there  is  astigmatism  of  2.00  D  with  the  rule,  because 
each  step  is  equivalent  to  1  diopter  of  corneal  refraction,  and  this  is  recorded 
+2.00  D  cyl.,  axis  90°,  or  -  2.00  D  cyl.,  axis  1S0°. 

If,  on  the  other  hand,  the  mires  separate  (Fig.  407,  2)  in  the  second  jHisition, 
there  is  astigmatism  against  the  rule.  For  examjile,  if  the  primary  position  is 
found  at  30°,  and  when  tlu;  tul)e  is  turned  to  the  left  until  the  long  i)ointer  reaches 
120°  aseparation  of  one  step  has  occurred,  there  is  astigmatism  of  one  diopter 
against  the  rule,  which  is  recorded  +  1.00  D  cyl.,  axis  30°,  or  —  1.00  D  cvl.,  axis 
120°. 

In  order  to  a.scertain  the  exact  number  of  steps  to  which  the  separation  of  the 
mires  in  the  second  position  is  equivalent,  they  are  approximated  by  moving  the 
sliding  mire  until  the  reflections  touch,  and  the  telescope  is  then  rotated  l)aek  to  the 
primary  j)osition.  The  mires  will  now  overlaj),  and  the  amount  of  astigmatism  can 
be  read  off  just  as  in  astigmatism  with  the  rule.  The  ol>server  sIhuiUI  rememlier, 
in  finding  the  jjrimary  i)()sifion,  not  to  turn  the  long  pointer  farther  than  15"  on 
each  side  of  0°  at  the  lower  margin  t)f  the  di.sk,  lest  he  record  jistignmtism  against 
the  rule  when  it  is  with  tlu;  rule,  and  vice  versa. 

The  upper  surface  of  the  are  carrying  the  mires  is  graduated  on  its  outer  circle 
to  show  dioj)ters  of  refra(;tion.  It  does  not  give  the  hyperopi.-i  or  myopia  of  the 
eye,  l)Ut  indicates  the  corneal  curvature.  On  tlie  el.'imp  of  eacli  mire  there  is  a  mark 
which  enables  one  to  read  at  a  ghince  from  this  graduated  arc  tiie  total  refraction  of 
each  meridian  of  the  cornea,     'ilie  total  refraction  of  at  least  one  conical  meridian 


THE   IJSE   OF   THE    OPHTHALMOMETER  765 

should  be  recorded,  and  preferably  the  one  of  least  refraction.  For  example,  if  the 
examiner  finds  in  the  right  eye  1  diopter  of  astigmatism  with  the  rule,  the  long 
pointer  being  at  75°  in  the  second  position,  and  the  right-hand  mire  at  23°  on  the 
graduated  arc,  the  refraction  may  be  recorded  O.  D.  43.00  D  =  1.00  D  cyl.,  axis 
75°  with  the  rule. 

If  so  desired,  the  astigmatism  can  be  read  from  the  graduated  arc  by  measuring 
alternately  the  meridians  of  greatest  and  least  refraction  of  the  cornea. 

■  On  the  right  of  the  inner  circle  of  the  arc  there  is  a  scale  graduated  from  6  to  10, 
each  space  being  divided  into  ten  equal  parts.  These  spaces  record  the  radius  of 
curvature  of  the  cornea  in  millimeters,  and  the  amount  is  indicated  bj*  a  mark  on 
the  clamp  of  the  traveling  mire. 

In  some  eyes  it  is  impossible  to  bring  into  a  continuous  line  the  two  lines  bisect- 
ing the  mires  of  the  ophthalmometer,  owing  to  irregular  astigmatism  or  conical 
cornea.  In  these  cases,  however,  the  instrument  is  perhaps  superior  to  all  other 
methods  of  corneal  measurement,  as  the  overlapping  or  separation  of  the  mires 


Fig.  408. — Javal-Schiotz  ophthalmometer  (model  of  1907). 

gives  a  clue  to  the  axes  of  the  meridians  of  least  and  greatest  corneal  cun^ature,  as 
well  as  the  amount  of  astigmatism. 

Not  infrequently  the  instrument  indicates  that  the  principal  meridians  of  the 
cornea  are  not  at  right  angles  to  each  other — for  example,  it  maj'  record  -|-  3.00  D 
cyl.,  axis  80°,  or  —  3.00  cj'l.,  axis  180°.  In  these  cases,  when  there  is  hyperopia, 
the  axis  of  the  cylinder  should  be  80°,  and  when  there  is  myopia,  180°. 

In  patients  with  heavy  overhanging  lids,  deep-set  eyes,  or  long  lashes  it  is  at 
times  extremely  difficult  or  even  impossible  to  measure  the  vertical  meridian  of  the 
cornea  with  the  ophthalmometer. 

Nothing  is  more  common  than  to  see  the  mires  separate  and  overlap  again,  so 
that  the  apparent  cur\-ature  of  the  cornea  seems  to  change  while  under  observ^ation. 
This  change  is  due  to  slight  movements  of  the  ej-e  which  bring  different  portions  of 
the  cornea  into  view.  It  is  difficult  for  most  patients  to  remain  long  in  the  required 
position  before  the  instrument,  and  hence  the  readings  should  be  rapid  as  well  as 
accurate. 


766 


APPENDIX 


As  to  the  correspondence  between  the  amount  of  corneal  astigmatism  indicated 
by  the  ophthalmometer  and  the  total  astigmatism  under  a  mydriatic,  there  is  a 
difference  of  opinion  among  observers.  Probably  the  rule  formulated  by  Burnett 
is,  in  the  main,  correct:  "For  the  total  subjective  astigmatism,  subtract  O.oO  D 
from  the  corneal  astigmatism  when  it  is  according  to  the  rule,  and  add  0.50  D  if  the 
corneal  astigmatism  is  against  the  rule." 

In  addition  to  the  Javal-Schiotz  ophthalmometer,  a  number  of 
excellent  models  may  be  obtained.  To  some  of  these  brief  reference 
has  been  made  on  page  116.  In  so  far  as  the  author's  practice  is  con- 
cerned, his  best  results  have  been  obtained  with  the  Javal  instrument 
(Fig.  408). 

The  ophthalmometer  is  exceedinglj'  useful,  and  one  of  the  most  im- 
portant of  all  the  instruments  of  precision  we  possess  for  the  diagnosis 


h'lG.  409. — The  tropometcr. 


of  astigmatism  of  the  cornea;  but  it  should  never  be  used  for  the  pre- 
scription of  glasses  to  the  exclusion  of  other  niotiiod.s — thotrial-liMises 
after  mydriasis,  and  retinoscopy.^ 

The  Use  of  the  Tropomcter. — ])r.  CI.  T.  Stevens-  attaches 
si)ocial  im])ortan('(!  to  the  dclcniiinations,  absolute  as  well  as  compara- 
tive, of  the  rotations  of  the  eyes,  since  he  believes  that  excessive 
tensions  upon  tiie  vertically  acting  muscles  of  the  eyes  often  induce 
converging  or  diverging  strabismus,  indepenticiitly  of  any  anomalous 

'  For  a  thorough  cxixisition  of  (lif  principlr.s  of  kcratonietry  the  istuih-nt  should 
consult  Carl  VW'iland,  .\rcliivcs  of  Ophllialnioiogy,  vol.  x\ii,  pp.  ;{7-t>l;  ()i)fi(iue 
l'hyHiolf)gi(|ur',  by  'I  sclicriiiiig,  pp.  4()  (IS. 

■^  Intcriuitional  ( )|)litli!iltiiologicul  CongresH,  lulinl)mj;li,  Augu.st,  ISttl;  .Vunalea 
d'()culiHti(|ii(',  .Ajuii  mid  .Imic,  iSKf). 


THE    USE    OF    THE    TROPOMETER 


767 


tension  of  the  laterally  acting  muscles,  and  that  many  conditions  of 
heterophoria  may  be  explained  in  a  hke  manner. 

The  most  favorable  rotations,  according  to  Dr.  Stevens,  are:  up- 
ward, 33°;  downward,  50°;  inward,  55°;  outward,  50°  (compare  with 
page  575). 

He  has  devised  an  instrument,  called  the  tropometer  (Fig.  409),  for 
the  determination  of  the  various  rotations,  a  description  of  which, 
kindly  revised  by  Dr.  Stevens,  follows : 

The  instrument  consists  essentially  of  a  telescope  in  which  an  inverted  image 
of  the  eye  is  found  at  the  ej-e-piece,  where  its  movements  can  be  observed  upon  a 


60- 
40  — 


/ 


20- 


TT^- 


f> 


Fig.  410. — The  long  line  between  and  at  right  angles  to  the  shorter  lines  divides 
two  similarly  graduated  scales  running  in  different  directions.  The  larger  circle  repre- 
sents the  outer  border  of  the  cornea,  the  edges  of  which  are  in  contact  with  the  two  strong 
lines.  The  interval  between  each  pair  of  short  lines  of  the  scale  is  ten  degrees  of  an 
arc,  commencing  at  the  strong  line  in  each  case.  If,  now,  the  head  of  the  person  exam- 
ined is  held  firmly  in  the  primary  position,  and  the  eye  caused  to  rotate  strongly  in  a 
given  direction,  the  arc  through  which  the  border  of  the  cornea  passes  may  be  accurately 
read  upon  the  scale.  In  the  figure  the  curved  dotted  line  represents  a  new  position  of 
the  border  of  the  cornea.  Suppose  that  the  person  examined  has  been  directed  to  look 
strongly  upward.  Then  the  cornea  has  moved  doun  the  scale,  and  reaches  the  point 
in  this  example  of  40°,  that  being  the  measure  of  this  rotation. 

By  means  of  the  small  lever  the  scale  can  be  placed  horizontally,  vertically,  or 
obliquely,  and  by  means  of  the  two  graduations  measurements  in  opposite  directions 
can  be  made. 

If  it  is  desired  to  determine  the  upward  rotation,  the  border  of  the  cornea  is  made 
to  coincide  with  the  strong  line  which  appears  in  the  upper  part  of  the  scale  at  the  right 
hand.  This  adjustment  is  made  by  means  of  the  milled  head  at  the  side  of  the  standard. 
As  the  eye  rotates  up,  the  image  moves  apparently  down.  In  determining  the  down- 
ward rotation  the  strong  line  at  the  lower  left-hand  side  of  the  scale  is  taken  as  the  point 
of  departure.  For  lateral  rotations  the  scale  is  turned  to  the  horizontal  position,  and 
the  corresponding  strong  lines  used  as  before. 

graduated  scale,  permitting  rotations  in  any  direction  to  be  measured.  A  prism  or 
a  diagonal  mirror  at  the  objective  end  of  the  telescope  permits  the  observer  to  sit  at 
the  side  of  the  observed.     By  means  of  a  head-rest  and  an  adjustable  stirrup  with  a 


768  APPENDIX 

wooden  bar,  which  the  observed  holds  closely  between  the  teeth,  the  head  may  be 
held  firmly  in  the  primary  position.  This  position  is  indicated  bj*  the  two  buttons 
at  the  extremities  of  the  jiuiding  rods. 

In  order  to  adjust  the  upper  border  of  the  cornea  to  the  line,  it  will  generally  be 
necessary  for  the  examiner  to  place  the  left  hand  upon  the  forehead  of  the  patient 
and  make  gentle  traction  of  the  upper  eyelid  by  the  thumb.  An  application  of  the 
hand  to  the  head  is  advi.sable  in  all  mea.surements,  as  by  this  means  the  examiner 
is  able  to  detect  even  a  slight  movement  of  the  head,  which  would  vitiate  any 
measurement  of  the  rotation. 

In  adjusting  the  head  to  the  head-rest  the  teeth  should  be  closed  upon  the 
wooden  bar  of  the  stirrup  with  force;  then,  after  adjusting  the  stirrup  to  the  proper 
height,  the  two  indicators  should  be  adjusted,  one  touching  the  glabella  or  ridge 
just  above  the  root  of  the  nose,  the  other  pressing  the  commissure  of  the  upper  lip 
close  below  the  nose.  By  pushing  the  stirrup  forward  or  backward  the  lower 
indicatorj'  button  should  be  at  a  distance  from  the  bone  equal  to  that  of  the  upper 
indicator. 

The  hoop  passing  around  the  head  is  designed  to  indicate,  when  the  knob 
presses  against  the  occipital  protuberance,  that  the  head  is  in  position  for  lateral 
measurements. 

If  the  cornea  is  large,  the  telescope  must  be  moved  backward  upon  the  base 
until  the  borders  of  the  cornea  just  encroach  upon  the  two  strong  lines  of  the  scale. 
WTien  the  cornea  is  small  the  tube  is  moved  forward. 

The  wooden  bar  of  the  stirrup  may  be  thrown  away  after  use  and  replaced  by 
another. 

For  measuring  declinations  of  the  retinal  meridians,  Dr.  Stevens  has  designed 
an  instrument  known  as  the  dinoscope.  For  a  full  description  of  this  instrument 
and  the  manner  of  using  it  the  student  should  consult  the  Medical  Record,  Feb- 
ruary 16,  1901,  where  he  will  find  Dr.  Stevens'  complete  directions. 

Localization  of  Foreign  bodies  in  the  Eyeball  with  the  Ront- 
gen  Rays. — The  following:;  paragraphs  have  boon  written  l\v  Dr. 
WiUiam  M.  Sweet,  and,  therefore,  in  his  own  words  describe  the 
method  which  he  has  originated  and  which  has  proved  to  be  most 
satisfactory: 

The  methods  of  locating  foreign  bodies  in  the  eyeball  by  means  of 
the  llontgen  rays  are  based  upon  the  study  of  the  shadow  of  the 
foreign  substance  on  the  radiograph  in  its  relation  to  the  shallow  of  one 
or  more  known  pomts  in  the  vicinity  of  the  eyeball.  These  fixed  points 
from  which  measurements  are  made  may  be  situated  on  the  skin  of  the 
eyelid  or  cheek,  or  suspended  in  front  of  the  eyeball.  If  an  apparatus 
is  emploj^ed  to  fix  the  position  of  the  j-raj'  tube  at  each  exposure,  only 
one  indicating  point  will  be  required,  but  with  two  fixed  points  of 
measurement  the  position  of  the  tube  at  the  time  the  radiograj>hs  are 
made  need  not  be  known. 

The  earlier  form  of  the  Sweet  localizing  apjiaralus  consisted  of  a 
small  j)lalform  to  which  the  heatl  of  the  i)aticnt  was  hnnly  damped. 
Two  ball-pointed  indicator  rods  were  used,  one  opposite  the  center  of 
the  cornea,  and  the  other  at  a  fixed  distance  to  the  temjioral  side. 
Two  exposures  were  made,  and  the  situation  of  the  steel  in  the  eye  was 
dctcriMiiicd  from  a  study  of  the  i)osition  of  iho  shadow  of  the  foreign 
body  on  the  two  ])lafcs  in  relation  to  tlu'  shadow  of  fh(>  two  inchcating 
rods. 

A  new  form  of  ai)])aratus  has  b(>en  d(>sigiu'(i,  in  which  only   one  indi- 


LOCALIZATION  OF  FOREIGN  BODIES  IN  THE  EYEBALL         769 

eating  rod  is  used.  The  planes  of  shadow  of  the  foreign  body  are  accu- 
rately determined  by  the  instrument  without  the  necessity  on  the  part 
of  the  operator  of  taking  measurements  from  the  plates  or  in  drawing 
lines  on  the  chart.  The  tube-holder,  indicating  ball,  and  plate-holder 
are  upon  a  movable  stage,  and  therefore  preserve  a  known  relation  to 
each  other  which  does  not  vary.  The  angle  of  the  rays  with  the  eye- 
ball and  the  distance  of  the  tube  from  the  plate  are  aways  the  same,  so 
that  one  indicator  is  sufficient,  and  this  consists  of  a  small  steel  ball 
supported  in  a  ring  of  transparent  celluloid.  The  setting  of  this  ball 
opposite  the  center  of  the  cornea  is  made  by  means  of  adjusting  screws 
conveniently  placed  on  the  frame  of  the  instrument.  Accuracy  in  the 
measurement  of  the  distance  of  the  indicating  ball  from  the  center  of 
the  cornea  is  secured  by  means  of  a  telescope  and  reflecting  mirror. 
The  mirror  gives  an  image  of  a  cross-wire  and  a  lateral  image  of  the 
cornea.  Through  the  telescope  the  observer  adjusts  the  instrument 
until  the  image  of  the  cross-wii^e  is  in  direct  contact  with  the  image  of 
the  summit  of  the  cornea  (Fig.  411).  When  the  adjustment  is  made, 
the  indicating  ball  is  exactly  10  mm.  from  the  center  of  the  cornea.  A 
miniature  incandescent  lamp,  mounted  in  an  adjustable  shade,  illumi- 
nates the  side  of  the  nose  of  the  patient,  insuring  a  well-hghted  image 
of  the  cornea  and  cross-wire. 


Fig.  411. — Image  of  cross-wire  and  cornea  (W.  M.  Sweet). 

Instead  of  a  ball  of  cotton  or  other  object  for  fixation,  as  in  the  older 
method,  a  circular  mirror  is  placed  at  a  distance  of  12  inches  above  the 
injured  eye.  The  patient  gazes  in  the  mirror  and  sees  a  reflected  image 
of  the  injured  eye  and  the  circular  celluloid  disk  with  the  steel  indicat- 
ing ball  in  its  center.  After  the  ball  has  been  adjusted  to  a  point  oppo- 
site the  center  of  the  cornea  of  the  injured  eye,  the  patient  by  fixing  the 
ball  with  the  seeing  eye  prevents  any  movement  of  the  eye  during  the 
exposures  and  holds  the  visual  line  of  the  injured  eye  parallel  with  the 
plate.  Two  exposures  are  made  upon  one  plate,  metallic  shutters  pro- 
tecting those  portions  of  the  plate  which  are  not  to  be  exposed  to  the 
rays. 

The  tube-holder  contains  the  usual  cylindric  lead-glass  shield  for 
protecting  the  operator  from  the  action  of  the  rays,  with  the  custom- 
ary lead  diaphragm.  The  central  orifice  of  the  diaphragm  is  covered 
with  aluminum,  which  offers  httle  obstruction  to  the  rays,  but  lessens 
the  risk  of  any  unfavorable  action  of  the  rays  upon  the  patient  and 
guards  against  possible  damage  to  the  eyes  in  the  event  of  breakage  of 
the  tube.  The  tube-holder  slides  upon  a  graduated  rod,  and  the  first 
exposure  is  made  with  the  indicator  at  zero,  in  which  position  the  rays 

49 


770 


APPENDIX 


pass  in  a  direction  corresponding  with  the  horizontal  plane  of  the  eye- 
ball. The  second  exposure  is  made  with  the  tube  at  its  farthest  point 
to  the  right  or  left  of  the  first  position,  depending  upon  which  eye  is  to 
be  examined. 

Since  the  relative  position  of  the  tube  in  reference  to  the  indicating 
ball  and  the  photographic  plate  remains  fixed  and  known,  the  x-rays  in 
passing  through  the  ej'eball  follow  a  definite  course,  which  is  alwaj'S 
the  same  for  the  two  separate  exposures.  It  is,  therefore,  possible  to 
indicate  on  the  localization  chart  the  direction  of  the  rays  at  the  two 


Fio.  412. — Localization  chart,  with  lines  roprcsonting  course  of  the  .r-rays  (one-half 
actual  size)  (W.  M.  Sweet). 

exposures,  and  this  has  been  done  in  t  lie  chart,  a  cojiy  of  which  is  repro- 
duced in  Fig.  412  reduced  in  size  ono-half.  Only  those  lines  represent- 
ing rays  2  mm.  apart  arc  reproduced,  but  each  line  is  drawn  witiithe 
rcfiuinid  amount  of  divergence  to  indicate  the  rays  as  coming  from  a 
point  the  dislaiicH!  of  the  tube  from  the  pli()togr;i])iiie  ])late. 

In  employing  the  new  appaiatus  (l-'ig.  W'A)  the  jointed  portion  con- 
taining the  upright  tube,  T,  is  raised,  and  the  i)atiL'nt  lies  with  the 
head  on  a  platform  of  iiard  fiber,  with  a  pillow  beneath  the  shoulders 


LOCALIZATION  OF  FOKEIGN  BODIES  IN  THE  EYEBALL 


771 


and  a  small  sand-bag  under  the  head  and  neck.  The  upright  supports 
for  holding  the  head  are  now  adjusted  by  means  of  the  wheel  1,  and  the 
jointed  part  of  the  apparatus  brought  down  in  position.  The  indicat- 
ing ball  is  now  roughtly  adjusted  until  it  is  opposite  the  center  of  the 
cornea  and  about  12  or  15  mm.  distant.  The  patient  looks  with  the 
uninjured  eye  into  the  mirror  {M)  and  fixes  upon  the  iris  or  cornea  of 
the  injured  eye,  or,  better,  upon  the  indicating  ball  in  the  center  of  the 
celluloid  disk.  The  indicating  ball  is  now  adjusted  directly  over  the 
corneal  center  by  means  of  the  wheels  2  and  3,  and  the  correctness  of 
the  position  verified  by  observation  through  an  opening  in  the  mirror 


Fig.  413. — Sweet's  apparatus  for  localizing  foreign  bodies  in  the  eyeball. 

(M).  The  operator  then  adjusts  the  light  of  the  small  electric  lamp  so 
that  the  side  of  the  nose  next  the  injured  eye  is  illuminated,  but  the 
light  is  not  thrown  into  the  eye.  With  this  area  lighted  it  is  possible, 
through  the  telescope  (T),  to  note  when  the  cross- wire  is  exactly 
tangent  with  the  summit  of  the  cornea.  The  movement  necessary 
to  secure  this  position  of  the  wire  is  made  by  means  of  the  adjusting 
wheel  4.  When  the  image  of  the  cross- wire  touches  the  image  of  the 
corneal  summit,  the  indicating  ball  is  exactly  10  mm.  from  the  eyeball. 
The  photographic  plate  is  inserted  beneath  the  spring  clips  (C,  C), 
the  shutters  {S,  S)  moved  so  that  the  center  area  is  open,  and  the  tube- 
holder  adjusted  to  the  zero  point  on  the  sliding  scale.  The  current  is 
turned  on,  and  one  exposure  made.  The  tube-carriage  is  then  moved 
to  the  limit  of  the  sliding  rod,  always  in  the  direction  of  the  chin  of  the 


in 


APPENDIX 


recumbent  patient  (to  the  end  marked  R  if  the  radiographs  are  made  of 
the  right  eye,  and  to  L  if  of  the  left  eye).  The  upper  shutter  is  moved 
to  cover  the  exposed  central  portion  of  the  plate  and  uncover  the  upper 
unexposed  portion.  The  current  is  again  turned  on  and  the  second 
exposure  made. 

After  the  plate  is  developed  it  is  placed  in  the  frame  P  (Fig.  413), 
containing  the  key  plate  or  focal  coordinates  (Fig.  414),  with  the  film 
side  of  the  radiograph  next  to  the  key  plate.  The  radiograph  is  moved 
until  the  shadow  of  the  indicating  ball  of  the  first  exposure  is  in  apposi- 
tion with  the  middle  ball  on  the  key  plate  and  the  heavy  horizontal 
line  of  the  radiograph  parallel  with  the  horizontal  line  on  the  plate. 

Focal  Co-ordinates 
For 
DrSureel's  ImproJed  Eife Localizer 

Made3u 
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Fig.  414. — Plate  showinR  focal  cofirdinatcs  (thrcc-fourths  actual  size)  (W.  M.  Sweet). 

Holding  the  frame  to  tiie  light,  there  is  noted  the  position  occupied 
by  the  shadow  of  the  foreign  body  with  respect  to  the  vertical  lines  of 
C  and  D.  A  reading  is  made  of  the  line  or  lines  which  pass  through 
the  body,  and  this  is  transferred  to  the  corresjmniliiig  lines  of  the  C 
or  D  scale  of  the  cliarl,  to  the  light  or  l(>ft  side.  (lejH'ndiiig  on  which 
eye  is  under  examination.  \\'ithout  moving  tiie  i)late  the  E  reading  is 
similarly  made  and  transferred  to  the  chart.  To  take  the  A  or  B 
reading  the  plate  is  shifted  slightly  until  tiie  image  of  the  indicating 
ball  on  the  second  exposure  coincides  with  the  "iligiit"  or  "Left" 
ball  of  tiie  vertical  coorchnatcs  .1  or  li.  The  line  or  lines  of  tiie  -I  or 
B  coordinates  wiiich  cross  the  shadow  of  the  body  are  noted  and  indi- 
cated on  the  A  or  H  lines  of  the  chart.  The  horizontal  coordinate  E 
should  be  the  same  in  botli  rea(hiigs.      If  the  focus  jjoiiit  on  the  anode 


LOCALIZATION  OF  FOEEIGN  BODIES  IN  THE  EYEBALL 


773 


of  the  tube  has  been  accurately  set  by  the  cross-hnes  on  the  lead-glass 
shield  of  the  tube-holder,  the  images  of  the  indicating  ball  on  the  plate 
will  coincide  simultaneously  with  those  on  the  transparent  key  plate, 
and  it  will  then  not  be  necessary  to  reset  the  plate  to  read  the  position 
of  the  A  and  B  coordinates. 

After  the  three  readings  have  been  transferred  to  the  chart,  the 
point  of  crossing  of  the  A  or  B  and  the  C  or  D  lines  is  found,  which 
gives  the  location  of  the  foreign  body  in  reference  to  the  front  view  of 
the  eyeball,  indicating  its  situation  above  or  below  the  center  of  the 
cornea  and  to  the  nasal  or  temporal  side  of  the  vertical  plane.  Where 
a,  vertical  line  from  this  point  crosses  the  E  reading  on  the  horizontal 


FiQ.  415. — Radiograph  of  foreign  body  in  eye  (three-fourths  actual  size)  (W.  M  Sweet). 

section  of  the  globe  it  gives  the  depth  of  the  body  in  the  eyeball  or 
orbit.  In  bodies  of  large  size  both  ends  should  be  localized  to  give  the 
position  in  which  the  body  rests  in  the  globe.  The  situation  of  the 
body  on  the  side  view  is  determined  by  transferring  its  measured  depth 
from  the  horizontal  section  and  its  distance  above  or  below  the  hori- 
zontal plane  from  the  front  view  localization. 

The  accuracy  of  the  localization  depends  only  upon  the  care  with 
which  the  operator  adjusts  the  indicating  ball  opposite  the  center  of  the 
cornea  and  at  the  definite  and  fixed  distance  from  it.  After  the  ex- 
posures are  made  and  the  plate  developed,  the  determination  of  the 
situation  of  the  foreign  body  is  simply  a  question  of  reading  from  a 
key  plate  and  transcribing  these  readings  to  the  chart. 


INDEX 


Note. — The  bold-face  folios  indicate  the  pages  on  which  the  subjects  are 
treated  in  extenso. 


Abderhalden  reaction,  302 
Abducens  nerve,  572 
Abduction,  572 

deficiency  of,  with  retraction  move- 
ment of  eyeball,  591 

test  for,  76 
Aberrant  choroidal  vein,  108 
Aberration,  122 
Ablatio  retinae,  490 
Ablepharia  partiaUs,  167 

totahs,  167 
Abnormal  accommodation,  41 

balance  of  ocular  muscles,  609 
AbnormaUties  of  visual  field,  88 
Abrin,  241 

Abrus  precatorius,  241 
Abscess,  lacrimal,  623 
of  infants,  624 
rupture  of,  624 
treatment  of,  627 

Ud,  197 

of  conjunctiva,  249 

of  cornea,  267 
ring,  306 

of  eyelid,  170,  197 

of  orbit,  645 

of  prelacrimal  sac,  623 

of  sclera,  316 

of  vitreous,  385,  451 

ring,  217 

after  cataract  extraction,  740 

subperiosteal,  631,  648 
Acanthosis  nigricans,  179 
Accessory  sinuses,  diseases  of,  643 
Accommodation,  35 

abnormal,  41 

ampUtude  of,  38,  72 

convergence  and,  relation  of,  44,  46 

definition,  72 

excessive,  41 

exercise  of  power  of,  37 

Grossmann's  theory,  37 

Helmholtz  theory,  36 

ill-sustained,  11 

in  aphakia,  448 

in  concomitant  strabismus,  597 

inequaUty  of,  41 

inertia  of,  41 

insufficiency  of,  41 

measurement  of,  by  skiascopy,  122 

mechanism  of,  35 

phenomena  of,  72 

power  of,  38 


Accommodation,  power  of,  insufficient, 
128 
range  of,  38,  72 

at  different  ages,  39,  40 
Duane's  method  of  testing,  39 
finding  of,  38 
formula  for  obtaining,  39 
table  of,  39 
reaction  of  pupil,  56,  61 
region  of,  38 
relative,  46,  72 

negative  part  of,  46 
positive  part  of,  46 
spasm  of,  in  hyperopia,  128 
spastic,  328 
subnormal,  128 
synkinesis,  56 
testing  of,  72 
Tscherning's  theory,  36 
Accommodative  asthenopia,  128 
heterophoria,  610 
movement  of  eyeball,  574 
Acetate  of  lead,  335 
Achromatopsia,  546 
Acne  rosacea  conjunctivitis,  201 
Acoin,  219,  275,  336,  494,  657,  689 
Actinomycosis,  lacrimal,  625 
Actual    cautery,    180,    262,    286,    739, 
760 
in  astigmatism,  156 
in  conical  cornea,  303 
in  corneal  disease,  690 
in  ectropion  and  entropion,  672 
Acuteness,  visual,  35 
normal,  35 
testing,  66 
Adams'  operation  for  ectropion,  670 
Adaptation  of  retina,  68 
Adaptometer,  69 
Adduction,  572 

test  for,  76 
Adenocarcinoma  of  conjunctiva,  252 
Adenoma  of  choroid,  392 

of  eyelids,  181 
Adherent  leukoma,  211,  278 
AdrenaUn,  200,  274,  627,  656,  658 

chlorid,  227,  243,  419,  659 
Advancement,  750 
Bruns'  method,  752 
capsulomuscular,     with    partial    re- 
section, 756 
Greenwood's  method,  753 
in  convergent  strabismus,  750 


775 


776 


INDEX 


Advancement,  Lancaster's  method,  753 
Landolt's  method,  751 
O'Connor's  method,  753 
of  external  rectus,  752 
of  Tenon's  capsule,_756 
Prince's  method,  752 
Schweigger's  method,  752 
Swanzy's  method,  751 
Todd's  method,  753_ 
Wiener's  method,  753 
Worth's  method,  753 
Adverse  prism,  614 
Afferent  pathway,  59,  00 
After-cataract,  441 
anterior  cortical,  440 
anterior  polar,  440 
discission  for,  746  ^ 

glaucoma  after,  746 
Knapp's  operation  for,  745 
operations  for,  746 
posterior  cortical,  440 

polar,  440 
treatment,  446 
Ziegler's  operation,  745 
Air  bubbles  in  vitreous,  319 
Albinism,  371 

semi-,  371 
Albinotic  fundus.  111 
Albolene,  246 
Albuminuric  choroiditis,  379 
retinitis,  473 

of  pregnancy,  476,  477 
Alcohol,  177,  189,  190,  272,  2^3,  297, 
298,  654 
amblyopia  from,  539,  552 
Almond  oil,  177 
Alopecia  of  eyelids,  193 
Alpha  angle,  41,  42 
Alphabet  keratitis,  297   _ 
Alternating  mydriasis,  65 
Alum,  2007206,  220,  239,  243,  245,  258 
Alveolar  sarcoma  of  choroid,  389 

of  conjunctiva,  253 
Alypin,  667,  658 
Amaurosis,  545 
hysteric,  555 
methyl-alcohol,  554 
optochin,  554 
partial  fugacious,  561 
quiniii,  553 
uremic,  551 
Amaurotic  cat's  eye.  385,  510 

family    idiocy,    changes    at    macula 
lutcain,  5i3,  514 
Amblyopes,  nocturnal,  558 
Amblyoi»ia,  645 
alcohol,  539,  552 
anti|)vrin,  553 
arsenic,  539,  553,  656 
asligiiialic,  545 
atoxyl,  539,  553,  555 
binitrotoluene,  553 
cannabis  indica,  539,  553^ 
carbon  bisulphid,  539,  553 

monoxid,  539 
central,  537 


Amblyopia,  central,  with  scotoma.  562 
chiasmal  central,  502 
chloral,  539,  553 
chlorate  of  potassium,  553 
chloroform,  539 
coffee,  553 
congenital,  436.  545 

for  colors,  54<) 
crossed,  556 

ethyl-hydrocuprein,  553 
exablep.sia,  598 
exanopsia,  546,  598 
from  abuse  of  drugs,  552 
from  aryolarsenates,  555 
from  diabetes,  540,  551 
from  disease,  540 
from  lo.ss  of  blood,  552 
from  thyroid  extract,  539 
functional,  during  pregnancy,  551 
glyco.suric,  551 
hysteric,  555 

in  concomitant  strabismus,  598 
in  shell-shock,  550 
intoxication,  540 
iodoform,  539,  553 
lead,  539,  552,  553 
malarial,  552 
male  fern,  553 
mahngering,  557 

mercury,  553 

methyl-alcohol,  553,  564 

nitrate  of  silver,  553 

nitrobenzol,  539,  553 

nitrophenol,  553 

of  visual  field,  661 
j       oil  of  wintergreen,  553 

opium,  539 
I       osmic  acid,  553 

pretended,  567 

quinin,  553 

reflex,  549 

salicylic  acid,  553 

stramonium,  539,  553 

sympathetic,  361 

tea,  553 

tobacco,  539 

toxic,  539,  562 

traumatic,  506,  549 

uremic,  551 
Aml)lvoscope,  604 

Worth-Hlack,  605 
Ametropia,  127 

axial,  127 

curvature,  127 

nicjusiiroment  of,  95 
definition,  127 
irtiMal  image  in,  35 
Aiiiftrnpic  choroiditis,  382 
Amnion,  staphyloma  of,  posterior,  315 
Ammonia  burns  of  eye,  .306 
Ammonium  chlorid,  2SI 
Amotio  retime,  490 
Amplitude  of  acconiniodation,  3S,  72 

lit  cciiivergeiice,   Ui,  SO 
.Vniyloid    di.seaso    of    conjunctiva,    2  1^ 
Ami'sthe.sia  retime,  501 


i 


t 


INDEX 


777 


Anagnostakis-Hotz  operation  for  entro- 
pion, 669 
Analgesia,  local  656 
Anaphylactic  keratitis,  292 

uveitis,  359,  365 
Anaphylaxis,  essence  of,  366 
Anel  syringe,  759 
Anemia     of     optic     nerve-head,     518 

of  retina,  461 
Anesthesia,  general,  655 
infiltration,  658 
local,  666 

Barker's  solution  for,  658 
Elschnig's  method,  659 
Seidel's  method,  659 
Siegrist's  method,  658 
of     retina,     462.     See     also   Retina, 
anesthesia  of. 
Aneurysms  in  retina,  501 

mihary,  with  retinitis,  501 
Angelucci's    method    of    cataract    ex- 
traction, 744 
Angioid  streaks  in  retina,  499 
Angioma,  cavernous,  of  choroid,  392 
of  eyeUd,  180 
of  choroid,  392 
of  eyelids,  180 
of  orbit,  637 
Angiomatosis  of  retina,  501 
Angiomegaly  of  eyelids,  180 
Angioneurotic    edema    of    conjunctiva, 
250 
of  eyeUd,  169 
Angiopathic  retinitis,  472 
Angiopathica  traumatica  retinae,  509 
Angiosarcoma  of  choroid,  389 

of  conjunctiva,  253 
Angiosclerosis,  retinal,  499 

retinitis  of,  498 

Angle,  alpha,  41,  42 

gamma,  41,  42 

in  convergent  strabismus,  599 
in  hyperopia,  133 
in  myopia,  136,  138,  139 
meter,  45 

centrads  and,  relation  of,  20 
prism-diopters    and,    relations    of, 
20 
of  convergence,  44 

meter,  44 
of  deviation,  19 
of  incidence,  18 
of  refraction,  18 
refracting,  of  prism,  18 
visual,  34 
Angular  conjunctivitis,  204 
Anhydro-sodiurn  carbonate,  355 
Aniridia,  346 
Anisocoria,  65 
Anisometropia,  156 
Ankyloblepharon,  167,  192 
Annular  posterior  staphyloma,  384 
sarcoma,  358 
scleritis,  315 

scotoma  in  glaucoma,  404 
Anodynes,  174 


Anomaloscope,  Nagel's,  72 
Anophoria,  74 
Anophthalmos,  630 
Anopsia,  quadrant  homonymous,  568 
Anotropia,  74 

Antepartum  conjunctivitis,  209 
Anterior  chamber,   alterations  in  con- 
tents, 347 
in  depth  of,  346 
angle  of,  cysts  of,  347 
anomalies  of,  346 
blood  in,  347 
cysticercus  in,  347 
deepening  of,  346 
delayed  restoration,  after  cataract 

extraction,  743 
examination    of,    by    transmitted 

hght,  103 
filaria  sanguinis  hominis  in,  347 
foreign  bodies  in,  347 
implantation  cyst  of,  347 
in  cataract,  430 

irrigation  of,  after  cataract  extrac- 
tion, 731 
parasites  in,  347 
pus  in,  347 
shallowing  of,  346 
tapping  of,  in  uveitis,  355 
tumors  of,  347 
choroiditis,  290,  314 
sclerotomy,  699 
staphyloma,  211 

total,  211 
synechise,  division  of,  699 
uveitis,  287 
Anthrax  of  eyeUd,  170 
An ti diphtheritic  serum,  242,  275,  740 
Antigonococcus  serum,  216,  219 
Antimetropia,  156 
Antipneumococcus  serum,  274 
Antipyrin,  227,  281,  536 

amblyopia,  553 
Antistaphylococcic  vaccine,  740 
Antistreptococcus  serum,  275 
An  ti  tetanic  serum,  318 
Antitoxin,  diphtheria,  222,  224 
Antityphoid    inoculations,     herpes     of 

cornea  following,  285 
Antrum  of  Highmore,  disease  of,  646 
empyema  of,  646 
fibroma  of,  647 
polypi  of,  647 
sarcoma  of,  647 
Apex  of  prism,  18 
Aphakia,  accommodation  in,  448 
congenital,  427 

from  removal  of  crystalline  lens,  447 
Aphakial  hyperopia,  127 
Apoplexy  of  retina,  494 
Appendix,  763 
Aqua  chlorini,  213,  216,  272 
Aqueous  humor,  changes  in  character 

of,  328 
Aquo-capsuUtis,  349 
Arc  of  propagation,  265 
Arcus  juvenalis,  309 


778 


INDEX 


Arcus  senilis,  297,  301 

lentis,  432 
Arecolin,  419 
Argamblyopia,  546 
Argentamin,  206,  216 
Argonin,  627 

Argyll  Robertson  pupil,.  63 
Argvria  conjunctivae,  258 
ArgVrol,  174,  200,  206,  207,  213,  215, 
"219,  221,  222,  238,  246,  271,  277, 
628,  687,  727,  740 
discoloration  from,  258 
ArgjTosis,  258 
Ariol,  276 

Aristol,  172,  178,  185,239,  256,  271,  628 
Arsenic,   172,   174,   195,  225,  228,  241, 
256,  262,  278,  293,  300,  315,  354, 
536,  552,  637 
amblyopia,  539,  553,  555 
Arsphenamin,  179,  256,  294,  314,  335, 

354,  380,  470 
Arterial  pulse,  retinal,  106 
Arteries  of  retina,  105 
Arteriosclerosis,  497 
Arterj^  hyaloid,  persistent,  459 
Arthritis  deformans,  337 

iritis  in,  337 
Artificial  epistaxis  before  operation  for 
glaucoma,  421 
eye,  711 

insertion  of,  711 
reformed,  712 
Snellen's,  712 
Aryolarsenates,  amblj-opia  from,  555 
Aspergillus  fumigatus,  266 

nigricans,  266 
Aspirin,  174,  296,  338,  354,  367 
Associated  action  of  pupil,  56 
Asteroid  hyalitis,  453 
Asthenopia,  41,  560 
accommodative,  128 
from  astigmatism,  150 
hysteric,  555 
muscular,  612 

nervous,  462.     See  also  Retina,  anes- 
thesia of. 
retinal,  556 
Astigmatic  amblyopia,  545 

lens,  155 
Astigmatism,  113,  145,  328 
against  rule,  147,  429 
asthenof)ia  from,  150 
clock-dial  chart  in,  152,  154 
compound,  determination  of,  114 
hyperopic,  150 

example  of,  154 
myopic,  150 

cxami)les  of,  154 
corneal  incision  for,  156 
correction  of,  152 
cylindric  lenses  in,  axes  of,  162 
definition,  Mti 
direct,  147,  151 
eye-strain  fmni,  150 
focussing  i>f   light    by   an   astigmatic 
eye  in,  1 17 


Astigmatism,   following    operation  for 
cataract,  447 
form  of  image  in.  147 
galvanocautery  for,  156 
glasses  for,  154 
headache  in,  150 
hyperopic,  compound,  150 

simple,  150 
in  myopia,  137,  140 
inverse,  147,  151 
iridectomy  for,  156 
!       irregular,  146,  156 
'       Johnson's  method  of  determining,  154 
I       lenticular,  146 

measurement  of,  152 
meridians  of,  146 
migraine  from,  150 
mixed,  151 
example,  154 
j  reading  glasses  in,  160,  161 

myopic,  compound,  1.50 
reading  glasses  in,  160,  161 
simple,  150 
obhque,  147 
operation  for,  156 
ordering  glasses  for,  155 
physiologic,  146 

principal  meridians  of  cornea  in,  146 
reading  gla.sses  in,  160  161 
recognition  of,  151 
regular,  146,  150 
seat  of,  146 
simple  hyperopic,  150 
example  of,  153 
myopic,  150 
example  of,  153 
skiascopy  in,  120.  122 
surgical  treatment  of,  156 
symptoms,  148 
Wallace's  chart  for,  153 
with  hj'peropia,  152 
with  myopia,  152 
with  rule,  147 
Astigmia,  145.     See  Astigmatism. 
Asymmetry,  chromatic,  53 
Atheromatous  ulcers,  280 

of  cornea,  280 
Atophan,  368 
Atoxyl.  293.  354,  368 

amblyopia,  539,  553,  555 
Atrabilin,  659 

Atrophia  gyrata  choroideitet  retinff,  4S6 
Atrophic  choroidorotinitis,  465 
Atrophy,  chontiditic,  374,  377 
circunipapillary,  3S4 
in  retinitis,  4(i() 
of  choroid,  senile  areolar,  3S0 
of  ciliary  body,  35S 
of  conjunctiva,  247 
of  cornea,  269 
of  corneal  margin,  302 
of  eyeball,  349.  3N5,  396 
of  iris,  32t),  334 
of  lacrimal  gland,  620 
of  o|)tic   nerve,   361,   399.   630.     See 
also  Optic  nerve,  atrofihy  of. 


h 


INDEX 


779 


Atrophy  of  retina,  465 
in  retinitis,  469 
senile  macular,  515 
senile  marginal,  299 
Atropin,   63,    111,    123,    142,   172,  206, 
216,  219,  224,  225,  239,  244,  246, 
257,  261,  270,  271,  273,  274,  276, 
282,  286,  293,  295,  296,  297,  298, 
304,  305,  306,  312,  314,  326,  334, 
339,  345,  354,  367,  372,  395,  460, 
466,  494,  508,  602,  603,  659,  690, 
699,  704,  709,  724,  725,  729,  733, 
734,  738,  739,  741,  743,  744,  746. 
conjunctivitis,  244 
sulphate,  334 
Atroscin,  125 

Attenuated  tubercle  of  iris,  340 
Autoserotherapy  for  hypopyon  keratitis, 

274 
Autoserum,  188 
Autotoxemic  iritis,  336 
Avulsion  of  optic  nerve,  541 
Axes  of  eye,  145 
of  lens,  26 
optic,  41 
secondary,  26 
visual,  41 
Axial  ametropia,  127 
cataract,  439 
hyperopia,  127 
neuritis,  537 
ray,  98 
Axis  finder  for  lens  testing,  164 
Azodolen,  277 

Bach's  accommodation  test,  56 
Bacillus  aerogenes  capsulatus,  650 
botulinus,  589 
Bulgarian,  355 
coh,  355 

diphtheritic,  224 
Hanke's,  307 
influenzae,  200 

conjunctivitis,  204 
lepra,  266 

Morax-Axenfeld,  230 
of  infected  marginal  ulcer,  267 
of  Klebs-Loffler,  222,  242 
of  Koch- Weeks,  230 

conjunctivitis,  202 
of     Morax-Axenfeld     conjunctivitis, 

204 
of  Petit,  266 
ozena,  266 

conjunctivitis  from,  201 
panophthalmitis,  387 
Pfeiffer's,  204 

capsulated,  266 
pseudo-tuberculosis  rodentium,  242 
pyocyaneus,  205,  266,  275 
pyogenes  fcetidus,  266 
subtihs,  200,  201,  266 
tubercle,  260,  266,  355 
tularense,  208 
xerosis,  200,  202,  223 
Bacteria  in  conjunctiva,  200 


Bacterins,  275,  740 
Bacterium  coU,  266,  350,  624 
conjunctivitis  from,  201 
Ballantyne's    classification    of    retinal 

arterial  pulse,  106 
Bandages,  654,  655 
Bar  reading  in  strabismus,  606 
Barker's  solution  for  local  anesthesia, 

658 
Barraquer's   method    of   extraction   of 

cataract,  744 
Barraquez      fat      implantation      into 

Tenon's  capsule,  715 
Base  of  prism,  18 

Basedow's  disease,  641.     See  also  Ex- 
ophthalmic goiter. 
Basham's  mixture,  628 
Belladonna,  174 
Bell's  palsy,  538 
Benzine,  654 
Benzol,  658 
BenzosaUn,  367 
Berger  corneal  loupe,  52 
Berry's  operation  for  staphyloma,  691 
Beta-eucain,  658 
Beta-naphthol,  239 
Biborate  of  sodium,  177,  200,  206 
Bicarbonate  of  soda,  177,  198,  246 
Bichlorid   of  mercury,    178,    206,    207, 
213,    216,    220,    221,    224,    238, 
240,    256,    271,    272,    275,    277, 
293,    305,    314,    318,    336,    354, 
368,    380,    387,    478,    497,    627, 
654,    656,    686,    687,    689,    709, 
712,    713,    727,    728,    729,    731, 
739,  740,  742,  747,  759 
with  iron,  454 
Bichlorid-vasehn,  305,  668,  727,  732 
Biconcave  lens,  30 
Biconvex  lens,  30 
Bifocal  lenses,  163 
Borsch's,  163 
concealed,  163 
Franklin,  166 
kryptok,  163 
spht,  166 
.  Ultex,  163 
Binasal  hemianopsia,  567 
Biniodid  of  mercury,  300,  444 
Binitrotoluene  amblyopia,  553 
Binocular  field  of  vision,  86 
fixation,  574 
magnifying  lens,  52 
maUngering,  test  for,  558 
single  vision,  575 

in  paralytic  strabismus,  580 
triplopia,  600 
vision,  574 
Bismuth  oxyiodid  tannate,  225 

subnitrate,  172 
Bissell's  blind-spot  slate,  90 
Bitemporal  hemianopsia,  566 
Bjerrum's  scotoma,  403,  404 

test  of  vision,  82 
Black  cataract,  430,  436 
eye,  197 


780 


INDEX 


Black     spot    of     macula     in    invopia, 

139 
Blastomycosis  of  eyelids,  171 
Blear  eye,  176 

Blennorrhagic      cunjunctivitis     neona- 
torum, acute,  212 
Blennorrhea,     acute,     in     adults,     217 
chronic,  217 

inclusion-,  of  newborn,  216 
lacrimal,  of  infants,  624 
of  conjunctiva,  acute,  208 
Blenolenicet  ointment,  219 

salve,  21 G 
Blepharitis,  174 
acaria,  177 
ciliaris,  175 
ulcerosa,  176 
etiology,  176 
hypertrophic,  176 
in  hyperopia,  129 
ionic  medication  in,  178 
non-ulcerative,  174 
pediculosa,  178 
simple,  175 
squamous,  175 
syphilitic,  179 
treatment,  177 
trichophytica,  177 
ulcerative,  175 
ulcerosa,  175 
vaccine,  172 
vasomotor,  175 
Blepharo-adenitis  ciliaris,  175 
Blepharochalasis,  190 
Blepharophimosis,  167,  192 
Blepharoplasty,  674,  677 
Burow's  method,  677 
d'Artha's  method,  678 
Dieffenbach's  method,  677 
Fricke's  method,  678 
Morax  method,  679 
Blepharoptosis,  190 
Blepharospasm,  189 
Blepharotomy,  666 

Blindness,  acute,  in  optic  neuritis,  524 
blue,  430,  474,  547 
color-.     See  also  Color-blindrtess. 
counterfeited,   92.     See   also  ,il/a/i;«- 

gcring. 
day,  559 
ecUp.se,  509 

from  aryolarsenates,  555 
from  ultra-violet  rays,  559 
green-,  547 
complete,  69 
methyl-alcohol,  554 
night-,  658 
red-,  69,  547 

(•()iiii)lete,  69 
red-green,  547 
.snow-,  659 
unilateral  reflex,  ()4 
violetr,  70,  474,  547 
Blind-spot,  enlargement  of,  (ilS 
Mariotte's,  89 
Hlate.  Hi.s.sell's,  90 


Blood-letting  in  vitreous  opacities,  454 
Blood-serum,     injections     in     vitreous 

hemorrhage,  4.56 
Blood-staining  of  cornea,  301 
Blood-ves.seLs,  formation  of.  in  vitreous, 
457 
of  conjunctiva,  48 
of  eye,  105 

distribution  of,  106 
Blue  ointment,  178 
pyoktanin,  628 
sclerotics,  323 
vision,    560 
Blue-bUndness,  430,  547 

in  albuminuric  retinitis,  474 
Bluestone,  261 
Blunt  hook,  693 

Bonnet's  method  of  enucleation,  709 
Boric  acid,  91,  170,  171.  172,  174,  178, 
200,    206,    207,    213,    214,    215, 
220,    221,    224,    225.    238,    243, 
245,  246,  261,  262,  270,  271,  272, 
277,    281,    314,    419,    620,    622, 
627,    628,    654,    656,    687,    690, 
692,    706,    712,    724,    727,    729, 
732,  747 
and  glycerin,  444 
and  sulphate  of  zinc,  628 
Borobismuth,  225,  262 
Boroglycerid,  195,  227,  229,  239 
Borsch's  bifocal  lenses,  163 
Borthen's  iridotasis,  706 
Bottle-makers'  cataract,  434 
Botulinus  bacillus,  589 
BotuUsm,  589 
Bowman's  operation  for  ptosis,  661 

stop  needle,  723 
Brain,  tumor  of,  523 
Brawny  infiltration  of  sclera,  315 
Bridge  coloboma  of  iris,  325 
Bright's  disejise,  retinitis  of,  473 
Bromid,  ethyl,  655 
of  potassium,  372,  444,  466,  .560 
of  sodium,  444 
Bromiils,  744 
Brossage,  227 
in  trachoma,  240 
modified,  for  trachoma,  687 
liruns'  method  of  advancement,  7.52 
Buccal  fistula,  (124 
Budge's  (•ili<)si)inal  center,  61 
Bulgarian  l)acillus,  355 
Bulging  cicatrix  after  cataract  extrac- 
tion, 741 
Buller's  shield,  220 
Bupiitii.tlinos,  42<) 
Bur(  liardt  s  iiilerii.ational  tests,  ()7 
Burns  of  conjunct iv.-i,  257 
of  ci)rnea,  .UKi 
of  eyelids,  lit8 
liurow's  luetiiod  of  Mcpliaroplasty,  677 
j)pcnilii)n  for  entropion,  tlCtO 

Cachectic  retinitis,  496 
('acodylate  of  sodium.  AOi] 
Cade,  oil  of,  172 


INDEX 


781 


Caffein,  657 

Calcareous  degeneration  of  cornea,  299 
Calcarine  fissure,  566 
Calcification  of  ciliary  body,  358 
Calcium  chlorid,  444 
lactate,  739 
salts  456 
Calomel,  172,  174,  208,  219,  225,  239, 
261,  262,  271,  278,  322 
conjunctivitis,  225 
Camphor,  172,  262 

water,  200 
Campimeter,  83,  404 
Canal  of  Cloquet,  459 
Canaliculi,  anomalies  of,  acquired,  622 
congenital,  622 
obstruction  of,  622 
polyp  of,  622 
slitting  of,  622,  757 

in  dacryocystitis  in  infants,  628 
streptothrix,  622 
Canaliculus  knife,  757 
Cannabis  indica,  amblyopia  from,  539, 

553 
Can  quoin's  paste,  185 
Canthoplasty,  241,  262,  666 
Canthotomy,  218,  666 
Capillary  congestion  of  retina,  460 
fistula,  624 

pulse  of  retinal  arteries,  106 
Capsular  cataract,  211,  428,  438,  442 
Capsule  forceps,  728 

Tenon's,  advancement  of,  756 

fat  implantation  into,   after  enu- 
cleation, 715 
Capsulolenticular  cataract,  428,  442 
Capsulopupillary  membrane,  324,  325 
Capsulotomv,    extraction    of    cataract 
without,  726 
preUminary,  in  cataract,  445 
extraction,  744 
Carbolic  acid,  174,  213,  216,  239,  272, 
286,  654 
burns  of  eye,  306 
liquid,  739 
Carbohzed  water,  627 
Carbon  bisulphid  amblyopia,'' 539,  553 
dioxid  snow,  180,  240 
monoxid  amblyopia,  539 
Carbonate  of  iron,  277 
Carcinoma,  metastatic,  of  ciliarv  body, 
358 
of  iris,  345 
of  choroid,  392 
of  cihary  body,  358 
of  eyeUds,  183 
Caries  of  orbit,  632 
Carotid,    ligation    of,    for    hemorrhage 

into  vitreous,  456 
Cartilage,  implantation  of,  after  enu- 
cleation, 714 
Caruncle,  affections  of,  257 

retraction  of,  after  tenotomy,  749 
Castor  oil,  246,  257 
Cataract,  427 

accommodative  strain  and,  436 


Cataract,  acute  glaucoma  in,  429 

acuteness  of  visior    after  extraction 

of,  447 
after-,    441,    428.     See    also    After- 
cataract. 
age  factor  in,  433 

in  prognosis,  443 
amber,  428 
anterior  capsular,  438 
anterior  chamber  in,  430 

cortical,  440 

polar,  440 
area  of  future  operation  in  progno- 
sis, 443 
artificial  ripening  of,  445 
astigmatism  following  operationj^for, 

447 
axial,  439 

black,  428,  430,  436 
blue,  428 

bottle-makers',  434 
capsular,  211,  428,  438,  442 
capsulolenticular,  428,  442 
catoptric  test  in,  430 
causes,  433 
central,  437 

lental,  437 
changes  in  lens  in,  433 
cholesterin  crystals  in,  436 
choroidal  congestion  in,  444 
classification  of,  428 
color  of  pupil  in,  430 
complete,  428,  440 

of  young,    436 

treatment,  446 
compHcated,  428,  440 
concussion,  435,  441 
condition  of,  in  prognosis,  443 

of  interior  of  eye  in  prognosis,  443 

of  patient  in  prognosis,'^443 
congenital  428,  436 

anterior  capsular,  438 

complete,  436 

fusiform,  439 

partial,  437 
treatment,  446 

polar,  438 

posterior  polar,  438 

punctate,  438 

pyramidal,  438 
Coppock,  440 
coralUform,  439 
cortical,  428 
couching,  722 
course,  431 
depressing  of,  722 
development  of,  431,  433 
dermogenetic,  434 
diagnosis,  430 
discission  for,  722 
discord,  440 
disease  and,  434 
disk-shaped,  446 
Doyne's,  440 
early,  433 
electricity  in,[4B5 


782 


INDEX 


Cataract,  ergotism  and,  435 

extraction  of.     See  Extraction  of  cata- 
ract. 

eye  diseases  and,  435 

families,  435 

fluid,  428 

from  electric  shock,  435 

from  injury,  441 

from  lightning-stroke,^  435 

from  x-ray  exposure,  435 

furnace-workers',  435 

fusiform,  439 

glasses  after  extraction  of,  447 

grav,  |436.     See  also  Cataract,  senile. 

hard,  428,  436 
extraction  of,  725 

hereditary  posterior  polar,  438 

heredity  and,  435 

hyaloid,  446 

hyperemia  of  conjunctiva  in,  429 

immature,  treatment  of,  445 

incomplete,  440 

inherited,  435 

intumescent,  433 

iridectomy  in,  444 

juyenile,  428,  436 

knife,  728 

lamellar,  437 

lens  after  extraction  of,  447 

lenticular,  428 

lightning-stroke,  435 

mature,  treatment,  446 

membranous,  442 

mobility    of    iris    in    prognosis,    443 

monocular  diplopia  in,  430 

Morgagnian,  433 

mydriatic  action  in  prognosis,  443 

naphthalin,  435 

needle-operation,  722 
after-treatment,  724 
instruments  required,  722 

nuclear,  428,  432 

oblique  illumination  for  detection  of, 
431 

occupation  and,  434 

opacities  in,  432 

operations  for,  722 

artificial  ei)istaxis  for,  421 

o|)hthalmosc()pic  diagnosis  in,   130 

overripeness  in,  433 

pain  in,  429 

partial,  42S 

congenital,  43(5 
treatment,  446 

patlKjJogic  anatomy,  4.31 

perinuclear,  437 

phot()i)liol)ia  in,  429 

polar,  43S 

I)olyopia  in,  430 

posterior  (cortical,  440 
polar,  374,  43S,  440 

preliininarv  (•a|)sulotoinv  in,  445 

presenile,  42S,  43t) 

prini;iry,  42.S 

jjrognosis,  442 

progressive  senile,  431 


Cataract,  punctate,  438 

pupil  in,  430 

pyramidal,  211,  438 
congenital,  438 

radium  in,  444 

raphanic,  435 

recUnation  of,  722 

refraction  in,  prognosis,  443 
treatment  444 

ripe,  431,  433.  442 

secondary,  428,  440,  441.     See  also 
After-cataract. 

senile,  428,  436 

sex  in,  434 

simple,  431,  436 

soft,  428,  436 

solution  operation  for,  722 

strise  of  refraction  in,  430 

subcapsular,  428 

suction  method  for,  724 

supranuclear,  428 

sjTnptomatic,  428 

symptoms,  429 

tetanj^,  437 

toxic  agents  and,  435 

traumatic,  428,  435,  441 

contusion-lesion  of  lens  in,  441 
ring-shaped    opacity    in,    441 

treatment,  444 

tj'pe  of,  in  prognosis,  443 

unilateral,  436 
treatment,  446 

varieties  of,  428 

visual  acuteness  in,  429 

white,  428 

with  glaucoma,  425 

zonular,  437 
riders  in,  437 
Cataracta  accreta,  331 

caerulea,  428 
Catarrh,  dry.  199 

epidemic,  207 
conjunctival.  202 

Fruehjahr's,  225 

silver,  213 

spring,  226 

with  swelling,  207 
Catarrhal  conjunctivitis,  201 
hemorrhagic,  202 

dacryocystitis,  ()23 

epidemic  conjunctivitis,  207 
Caterpill.ar   hairs,    conjunctivitis   from, 

24() 
Cat-like  pupils,  54 
Catoptri<'  |)((wer  of  mirror,  94 

test  in  cataract,  430 
Cat's  eye,  amaurotic,  385 
Caustic  paste,  1S7 
Cauterization  in  conical  cornea,  692 
Cautery.     See  Actiuil  cautery. 
Cavernous  angioma  of  choroid,  392 

atroi)hy  of  optic  nerve,  399 

growths  of  evelids,  ISO 

Slims,  tlironiliosis  of,  (»;i5 
Cell-nests,  1S5 
CeliuUtiH  of  orbit.  633 


INDEX 


783 


Cellulitis  of  orbit  after  tenotomy,  749 
causes,  634 
prognosis,  634 
progress,  634 
treatment,  635 
Center  of  rotation,  41 

optical,  determination  of,  164 
of  lens,  25 
Centrads,  19 

meter  angle  and,  relations  of,  20 

prism-diopters  and,  relative  values, 
20 

Wallace's  table  of  relative  values  of, 
20 
Central  amblyopia,  537 

heterophoria,  610 

scotomas,  563 
Centrifugal  pathway,  59,  60 
Cephalic  mucous  membrane,  examina- 
tion of,  277 
Cerebral  cortex  reflex  of  pupil,  57,  61 

decompression  in  optic  neuritis,  527 
Cervical  sympathetic,  59 

irritation    of,    dilatation    of    pupil 
from,  61 
Chalazia  in  hj^peropia,  129 
Chalazion,  171 

causes  of,  182 

curet,  660 

external,  removal,  660 

pathologic  anatomy,  183 

removal,  660 

symptoms,  182 

treatment,  183 
Chambers-Inskeep  ophthalmometer,  1 16 
Chandler's  method  of  cataract  extrac- 
tion, 744 
Chemosis,    filtration,    of     conjunctiva, 
after    cataract    extraction,    743 

of  conjunctiva,  250,  630 
Cherry-red  spot  of  macula,  502 
Chiasmal  central  amblyopia,  562 
Chlamydozoa,  231 
Chloracetic  acid,  185 
Chloral,  177,  419 

amblyopia,  539,  553 
Chlorate  of  potash,  222 

of  potassium,  185 
amblyopia  from,  553 
Chlorid  of  iron,  277,  293 

of  sodium,  222,  275,  729,  731 

of  zinc,  207 
Chlorin    water,    intraocular    injections 

of,  452 
Chloroform,  655 

amblyopia,  539 
Chlorosone,  246 
Choked  disk,  518,  519,  473.     See  also 

Optic  neuritis. 
Cholesterin    crystals   in    cataract,    436 

in  vitreous,  456 
Chorea,  habit,  189 
Chorioretinitis,  467 

circumpapillaris,  471 

diffuse,  467 

famihal,  379 


Chorioretinitis,  proliferating,  481 
Choroid,  110 

absence  of  pigment  in,  371 
adenoma  of,  392 
angioma  of,  392 
angiosarcoma  of,  389 
atrophy  of,  384 

senile  areolar,  380 
blood-vessels  of,  161 
calcareous  degeneration  of,  396 
carcinoma  of,  392 
cavernous  angioma  of,  392 
coloboma  of,  370 

atypical,  370 
congenital  anomaUes  of,  370 
congestion  of,  372 

in  hyperopia,  129 
detachment  of,  395 
diseases  of,  370 
enchondroma  of,  392 
foreign  bodies  in,  394 
hemorrhage  into,  395 
hyperemia  of,  371 

treatment,  372 
injuries  of,  394 

interfascicular  endotheHoma  of,  389 
leukosarcoma  of,  387,  388 
melanoma  of,  390 
melanosarcoma  of,  388 
obsolescent  tubercles  of,  394 
ossification  of,  396 
perithelioma  of,  389 
pigment  heaping  in,  372 
rupture  of,  395 
sarcoma  of,  388,  389 

alveolar,  389 

anomalous,  390 

diagnosis,  391 

diaphanoscopy  in,  391 

diffuse,  389 

enucleation  for,  392 

episcleral  tumor  stage,  391 

first  stage,  390 

flat,  389 

fungus  state,  391 

generaUzation  stage,  391 

glaucomatous  stage,  390 

inflammatory  stage,  390 

metastatic  stage,  391 

ophthalmodiaphanoscopy  in,  391 

pathology,  388 

prognosis,  392 

ring,  389 

symptoms,  390 

telangiectatic,  392 

transillumination  in,  391 

treatment,  392 
sclerosis  of,  primary,  381 
senile  areolar  atrophy  of,  380 
suppurative,  treatment,  387 
tuberculosis  of,  393 

chronic,  393 

treatment,  394 
tuberculous  tumor  of,  393 
tumors  of,  388 

diagnosis,  391 


784 


INDEX 


Choroid,  tumors  of,  pathology,  388 

prognosis,  392 

symptoms,  390 

tuberculous,  393 

treatment,  392 
verrucosities  of,  382 
woolly,  372 
wounds  of,  394 
Choroidal  dust,  393 
fissure,  370 
ring,  104 

vein,  aberrant,  108 
vessels,  sclerosis  of,  380,  381 
Choroideremia,  371 
Choroiditic  atrophy,  374,  377 
Choroiditis,  361,  372 
acute,  352,  375 

plastic,  352 
albuminuric,  379 
ametropic,  382 
anterior,  290.  314,  378 

causes,  378 

prognosis,  379 

treatment,  380 
areolaris,  381 
atrophic,  372 
causes,  372 
central,  380 

causes,  382 

treatment,  382 
chronic,  375,  376 
circumscribed  plastic,  377 
complications,  373 
course,  373 
deep,  374,  375 
diagnosis,  373 
diffuse  exudative,  375 
disseminated,  376,  379 
epitheUal,  374 
from     diseases    of    nasal    accessory 

sinuses,  647 
hemorrhagic,  384 
hereditary,  379 
localized  exudative,  377 
myopic,  384 

non-suppurative  exudative,  374 
old,  373 
pain  in,  373 

pathologic  anatomy,  374 
photopsies  in,  373 
pigment  in,  373 

hoai)ing  in,  372 
pigiiiciilation  of  retina  in,  377 
pigmented,  379 
plastic,  374 
prognosis,  373,  374 
purulent,  374 
recent,  372,  375 
senile  gut  I  ate,  381 
serous,  374 
suiHTficial,  374 
suppurative,  ;{7I,  385 

causes,  ."iSd 

enucleation  in,  3S7 

evisceration  in,  3S8 

paiKipht  lialniitis  froiii,  3.S('» 


Choroiditis,  suppurative,  pathology,  386 
phthisis  bidbi  from,  386 
prognosis,  387 
symptoms,  385 
symptoms,  372 
syphihtic,  372 
traumatic,  372,  379 
treatment,  374 
tuberculous,  372,  379 
unclassified  forms  of,  383 
with  descemetitis,  377 
Choroidoretinitis,  373,  374,  376.  467 
atrophic,  465 
hereditary  syphilitic,  470 
miliary,  372 
Chromatic  asymmetry,  53 

sense,  feeble,  69 
Chromatometers,  72 
Chromidrosis  of  eyeUds,  196 

palpebral,  196 
Chryosphanic  acid,  244 
Chrysarobin  conjunctivitis,  244 
Cicatrical   orbital  socket,    Esser's  epi- 
thelial inlay  for,  680 
Maxwells  operation  to  enlarge, 

681 
operations  for  prosthesis  in,  679 
Schwenk  and  Posey's  operation 

to  enlarge,  681 
Wiener's    operation    to    enlarge. 
681 
trachoma,  234,  236 
Cicatrix,  bulging,  after  cataract  extrac- 
tion, 741 
cvstoid,    after    cataract    extraction, 
741 
after  iridecfomv  in  glaucoma.  422 
Ciha,  false.  192 

premature  graynoss  of,  193 
Ciliary  body,  adenoma  of,  358 
atrophy  of,  358 
calcification  of,  358 
carcinoma  of,  358 
iliktyoma  of,  358 
diseases  of,  348 
epithelial  hyperplasia  of,  358 
glands  of,  353 
ginnma  of,  356,  357 

precocious,  357 
hypernephroma  of,  358 
inflaiiunation  of,  348,  349 
injuries  of,  'AM 

treatment,  356 
leprosy  nodules  of,  358 
metastatic  carcinoma  of,  358 
myonui  of.  358 
myosarcoma  of,  358 
o.ssification  of,  358 
sarcoma  of.  357 
secondary  glioma  of,  358 
senile  (h-generation  of.  358 
sy  pill  lis  of,  'M^>(\ 
syphiloma  of.  3."i() 
tcMatonewronia  enil>r\ onah'  of,  35S 
tuberculosis  of,  ,'{.")S 
tumors  of,  357 


INDEX 


785 


Ciliary  congestion,  49 

epithelial  tumors,  358 

nerve,  neuroma  of,  358 

pain,  328 

staphyloma,  316 
Cilioretinal  vessel,  107 

in   obstruction   of    central    arter}', 
502,  503,  504 
Ciliospinal  center,  61 
Cilium  forceps,  659 
Cinnamate  of  sodium,  312 
Circular  ulcer,  268 
Circumcising  cornea,  709 
Circumcorneal  zone,  49 
Circumpapillarj'  atrophy,  384 
Circumscribed    parenchvmatous    kera- 
titis, 295 
Citrate  of  lithium,  278,  314 
Citrine  ointment,  177 
Cleft  eyehd,  167 
CUnoscope,  768 
Clock-dial  chart  in  astigmatism,   152, 

154 
Clonic  cramp  of  eyelids,  189 
Cloquet,  canal  of,  459 
Coagulose,  456 

Cobalt  test  for  ocular  muscles,  79 
Cocain,  50,  62,  111,  124,  125,  186,  191, 
244,  257,  261,  270,  273,  274,  281, 
303,  328,  420,  430,  494,  627,  656, 
657,  658,  660,  689,  690,  692,  723, 
727,  729 

hydrochlorid,  125 
Coccidia,  196 
Cocoa  butter.  188 
Codein,  219,  278,  338 
Cod-hver  oil,  178,  195,  225,  241,  247, 

262,    277,    283,   293,   314,    559,    628, 

633 
Coffee  amblyopia,  553 
Cohesion  of  evehds,  167 
Colchicin,  314 
Colchicum,  278,  314 
Collapsing  pulse  of  retinal  arteries,  106 
ColUns'  binocular  magnifier,  56 

magnifier,  52 
Collodion,  193,  664 
Colloid  change  in  macular  region,  382 

degeneration     of     conjunctiva,     248 
Collyria,  656 
Coloboma,  541, 

bridge,  325 

extrapapillarj^,  370 

macular,  370 

of  choroid,  370 
atypical,  370 

of  crystalline  lens,  427 

of  eyelids,  167 

of  iris,  325 

of  sheath  of  optic  nerve,  516 

of  vitreous,  459 

of  zone  of  Zinn,  427 

palpebrse,  167 

width  and  depth  of,  696 
Color,  direct  vision  for,  72 

of  iris,  52 
50 


Color  test,  comphmentary,  89 
for  scotomas,  89 

vision,  theory  of,  547 
Color-blindness,  69,  546 

chromatometric  test  for,  72 

congenital,  546 
partial,  546 
total,  546,  548 

Helmholtz's  theorj',  546 

Holmgren's  test  for,  69 

incomplete,  69 

Jenning's  self  recording  test  for,  70 

lantern  test  for,  70 

Nagel's  card  test,  71 

special  tests,  72 

spectroscopic  test  for,  72 

Stelling's  pseudo-isochromatic  plates 
for  testing,  71 

Thomson's  test  for,  70 
Color-field,  86 

inversion  of,  556 
Color-sense,  69 
Combined  extraction  of  cataract,   726 

iridectomy  and  sclerectomy,  700 
Comitant  heterophoria,  610 

strabismus,  596 
Commotio  retinae,  506,  508 
Concave    lens,    23.     See    also    Lenses, 
concave. 

mirror,  93,  123 

skiascopy  with,  118 
Concavoconvex  lens,  30 
Concealed  bifocal  lenses,  163 
Concomitant  strabismus,  596 
Concussion  cataract,  435,  441 

of  eyeball,  652 
Cone,  516 
Confrontation   methods    in   measuring 

limits  of  visual  field,  81 
Congenital  amblyopia,  436,  545 

aphakia,  427 

cataract,  428,  436 

deviation,  591 

distichiasis,  168 

ectropion  of  urea,  326 

fistula  of  eyelid,  169 

iridodialj'sis,  324 

leukomas,  307 

paralysis  of  exterior  ocular  muscles, 
591 

pigmentation  of  sclera,  322 

pterygium,  168 

ptosis,  169 

total  color-bhndness,  548 

word-bhndness,  548 
Congestion,    capillar}-,    of    retina,    460 

ciliary,  49 

of  disk,  517 
Conical  cornea,  302 

operations  for,  692 
Conium,  189 
Conjugate  deviation,  594 
of  head  and  eves,  595 

foci,  24 

of  concave  lens,  25 
of  convex  lens,  24 


786 


INDEX 


Conjunctiva,  abscess  of,  249 
acute  blennorrhea  of,  208 
adenocarcinoma  of,  252 
alveolar  sarcoma  of,  253 
amyloid  disease  of,  248 
angioneurotic  edema  of,  250 
angiosarcoma  of,  253 
argyria  of,  258 
atrophy  of,  247 
bacteria  in,  200 
blood-vessels  of,  48 
burns  of,  257 
chemosis  of,  250,  630 
colloid  degeneration  of,  248 
congenital  anomalies  of,  199 
cysts  of,  250,  251 
degeneration  of,  248 
dermo-epithelioma  of,  251 
discoloration  of,  258 
diseases  of,  199 
ecchymosis  of,  249    . 
eczema  of,  224 
edema  of,  250 
emphysema  of,  250 
endothelioma  of,  253 
epibult)ar  sarcoma  of,  253 
epithelial  cystoma  of,  251 
epithelioma  of,  252 
essential  shrinking  of,  256 
filtration  chemosis  of,  after  cataract 
extraction,  743 

foreign  bodies  in,  256 
from     diseases    of    nasal    accessory 
sinuses,  647 

hemorrhage  from,  250 

hyaUne  degeneration  of,  248 

hyperemia  of,  199 
causes,  199 
in  cataract,  429 
symptoms,  199 
treatment,  200 

implantation  cysts  of,  251 

inflammation  of,  200.     See  also  Con- 
junctivitis. 

injuries  of,  256 

lepra  of,  254 

lymphangiectasis  of,  250 

lymphoma  of,  241 

lupus  of,  254 

melanocarcinoma  of,  253 

melanoma  of,  253 

melanosis  of,  251 

moles  of,  251 

naivus  pigmentosus  of,  251 

operations  on,  681 

pemi)higus  of,  256 

peribulbar  epithelioma  of,  252 

pigment  spots  on,  25;i 

pseiidotulMTculosis  (»f,  216 

Harcoma  of,  253 

sidcrosis  of,  25S 

sporotrichosis  of,  212 

streptococcus  di|)htheria  of,  222 

syphilis  of,  250 

tuberculosis  of,  255 
diagnosis,  255 


Conjunctiva,  tuberculosis  of,  prognosis, 
255 
treatment,  255 
tumors  of,  250 
ulcers  of,  249 
wounds  of,  257 

xerosis  of,   with  infantile  ulceration 
of  cornea,  282 
Conjunctival    catarrh,    epidemic,    202 
flaps,  sUding,  738 
sac,  temperature  of,  50 
Conjunctivitis,  200 
acne  rosacea,  201,  208 
acute  contagious,  202 
diagnosis,  203 
etiology,  202 
prognosis,  203 
sjTnptoms,  202 
treatment,  206 
granular,  230,  236 
mucopurulent,  202 
angular,  204 
antepartum,  209 
associated,  201 
atropin,  244 

blennorrhagic,  neonatorum,  acute,  212 
calomel,  225 
catarrhal,  201 
epidemic,  207 
hemorrhagic,  202 

chronic,  242 
granular,  230 
treatment,  219,  243 
chrysarobin,  244 
communicable,  202 
croupous,  221 
causes,  221 
diagnosis,  222 
symptoms,  222 
treatment,  222 
diphtheritic,  223 
causes,  223 
diagnosis,  224 
prognosis,  224 
svmptoms,  223 
treatment,  224 
diplobacillus,  204 
symptoms,  204 
treatment,  207 
Egyi)tian,    213 
exanthematous.  201,  207 

treatment,  208 
follicular,  228 
causes,    22S 
diagnosis,  229 
prognosis,  229 
svm|)toms,  22S 
treat nicnt.  229 
follicularis  simplex,  228 
'<       folHciilosis  of,  228 
'        from  aiiilin  dyes,  244 

from  Bacillus  |)vocviuicu8,  205 

s\il>lilis,  201 
from  Hactfriiiin  coli,  201 
from  caterpillar  hairs,  246 
from  chryosphanic  acid,  244 


INDEX 


787 


Conjunctivitis  from  ozena  bacillus,  201 
from  plant  hairs,  244,  247 
from  sting  of  insects,  244 
from  venom  of  serpents,  244 
gonorrheal,  208,  217 

corneal  ulceration  in,  219 

diagnosis,  218 

epibulbar,  220 

metastatic,  220 

prognosis,  218 

prophylaxis,  220 

symptoms,  217 

treatment,  218 
granular,   229.     See  also   Trachoma. 
in  hyperopia,  129 
infectious,  241 

necrotic,  208 
influenza  bacillus,  204 

pseudomembranous    form,     204 
treatment,  207 
Koch- Weeks'  bacillus,  202 
lacrimal,  243,  623 
larval,  244 
mechanical,  201 
meibomiana,  242 
membrane-forming,  223 
membranous,  210,  221 
meningococcus,  201 
•  metastatic  gonorrheal,  220 
micrococcus  catarrhalis,  201 
military,  243 

Morax-Axenfeld  bacillus,  204 
mustard  gas,  246 
neonatorum,  208 

acute  blennorrhagic,  212 

causes,  208 

diagnosis,  212 

prognosis,  212 

prophylaxis,  212 

symptoms,  209 

treatment,  213 
nodosa,  246 

non-specific  purulent,  221 
parasitic,  244 
Parinaud's,  241 
periodic  hyperplastic,  225 
petrificans,  248 
phlyctenular,  224 

causes,  224 

symptoms,  225 

treatment,  225 
plastic,  221 
pneumococcus,  203 

symptoms,  203 

treatment,  207 
podophyUin,  244 
poisonous  gas,  245 
treatment,  246 
provoked,  245 
pseudomembranous,  221 

recurring,  222 
purulent,  208 

in  young  girls,  216 
samoan,  208 
septic,  241 
sicca,  243 


Conjunctivitis,  simple,  201 

causes,  201 

duration,  202 

prognosis,  202 

symptoms,  201 

treatment,  205 
spring,  225,  226 
squirrel  plague,  208 
staphylococcus,  201 
subacute,  204 
swimming-bath,  204 
symptom'atic,  201 
syphihtic,  250 
tea-leaf,  206 
toxic,  201,  244 

trachomatous,  229.     See  also  Trach- 
oma. 
traumatic,  244 
treatment,  205 
unusual  forms  of,  208 
vernal,  225 

causes,  226 

pathologic  histology,  227 

prognosis,  227 

symptoms,  226 

treatment,  227 
Widmark's,  249 
x-ray,  244,  560 
Conjunctivoplasty,  681 
Kuhnt's  method,  683 
Connective-tissue  ring,  104 
Consensual  Hght-reflex  of  pupil,  56,  60 
Contagious  epitheUoma,  196       ^ 
Contraction  of  dilatator  pupiUse,  61 

of  pupil,  61,  62 
Controlled   reading   of   Javal  in   stra- 
bismus, 606 
Contusion  lesion  of  lens,  441 

of  eyeball,  652 
Conus,  106,  517 

congenital  inferior,  517 
in  myopia,  137 
surgical,  541 
underlying,  106 
Convergence,  43,  44 

accommodation  and,  relation  of,  44, 

46 
ampUtude  of,  46,  80 
angle  of,  44 
anomaUes  of  pupils,  64 
cramp,  609 
excess,  in  heterophoria,  610 

non-accommodative,  609 
far  point  of,  46 

in  concomitant  strabismus,  597 
insuflSciency  of,  577 

in  heterophoria,  611 
meter  angles  of,  44 
movement  of  eyeball,  574 
near  point  of,  46 

test  for,  76 
paralysis,  595 

in  heterophoria,  611 

reaction  of  pupil,  56,  61 

neurotonic,  ■  65 

paradoxic,  66 


788 


INDEX 


Convergence,  spasm  of,  595,  596,  609 

unit  of,  44 
Convergent  strabismus,   43,    128,   576, 
582.     See  also  Strabisrmis,  convergent. 
Convex    lens,    23.     See    also    Lenses, 
convex. 
mirror,  94 
Convexoconcave  lens,  30 
Cooper-Swanzy     sign     in    goiter,    642 
Copper  citrate,  239 
in  eve,  319 
sulphate,  221,  686 
Coppook  cataract,  440 
Coralliform  cataract,  439 
Cordite  in  cornea,  304 
Corectopia,  324 
Corelysis,  344 
Cornea,  abscess  of,  267  • 
-  ring,  306 
treatment,  273 
variolar,  268 
arcus  senilis  of,  301 
atrophy  of,  269 

margin  of,  302 
band-like  opacity  of,  301 
blood-staining  of,  301 
burns  of,  306 

calcareous  degeneration  of,  299 
central    parenchymatous   infiltration 

of,  295 
changes   in,  in  exophthalmic  goiter, 

642 
circumcising,  709 
congenital  anomalies  of,  309 
flatness  of,  310 
melanosis  of,  310 
opacities  of,  309 
staphyloma  of,  309 
conical,  302 

oi)erations  for,  302,  092 
treatment,  302 
cordite  in,  304 
cysts  of,  307 

deep  scrofulous  infiltrations  of,  261 
degeneration  of,  calcareous,  299 
family  punctate,  298 
marginal,  299 
primary  progressive,  299 
si)ot(e('l,  299 
dermoid  tumor  of,  30S 
diseases  of,  259 
dystrophy  of,  cpitlichal,  300 
eczema  of,  259 
cpaulct-Hke  swelling  of,  2X9 
cpitliclial  cysts  of,  309 

dystropliy  of,  300 
erosions  of,  304 
relapsing,  305 
examination  of,  1>\'  trunsiuil  tc(l  liglit, 
■   103 

faiiiilv  |>uncta(<'  (Icgciicratioii  of,  2US 
fislula  of,  2Si 
foreign  boilies  in,  303 
guiiinia  of,  29't 
gut  (ate  ()|)afitics  of,  29S 
haziness  of,  32S 


Cornea,  herpes  of,  173,  285 

after  cataract  extraction,  742 

relapsing,  295 
image  of,  94 

size  of,  95 
implantation  cysts  of,  309 
incision  of,  in  astigmatism,  156 
infantile  ulceration  of,   with   xerosis 

of  conjunctiva,  282 
infiltration  of,  peripheral  annular,  306 
inflammation     of,      257.     See      also 

Keratitis. 
injuries  of,  303 
inspection  of,  50 
lattice-form  opacity  of,  298 
lead  incrustation  of,  301 
leprosy  of,  254 
leukoma  of,  278 
lupus  of,  299 
lymphatic  cysts  of,  309 
macula  of,  278 
marginal  degeneration  of,  299 

ectasis  of,  299 
massage  of,  281 
nebula  of,  278 
necrosis  of,  282 
nodular  opacities  of,  298 
obstetric  injuries  of,  307 
opacity  of,  298 

after  cataract  extraction,  742 

band-like,  301 

clearing  of,  282 

congenital,  309 

grilMike,  298 

interstitial  punctate,  299 

myopia  from,  134 

nodular,  298 

primary,  300 

reticular,  299 

striate  clearing  of,  282 

zonular,  300 
operations  on,  689 
l)aracentesis  of,  272,  ()S9 
perforation  of,  impemling,  treatment, 
272 

treatment,  273 
phlyctcMular  ulcer  of,  260 
pigMH'utation  of,  .310 

jxTiphcral,  310 
plana,  310 

powder  grains  in,  'M)\ 
primary  opacity  of,  300 

|)rogressiye    degeneration    of,j299 
retention    cysts    of,    true    Kinphatic, 

309 
reticular  ojjacities  of,  299 
ring  abscess  of,  'MM\ 
rodent  ulcer  of,  268 
rupture  of,  317 
scalds  of,  306 
sciir-libroma  of,  307 
sclerosis  of.  302,  309 
senile  niargimd  atrophy  of,  299 
sensibility  of,  .51 

in  glaucoma,  401 
si)oltc(l  degeneration  of,  299 


i 


INDEX 


789 


Cornea,  staphyloma  of,  278 

congenital  anterior,  309 
tattooing  of,  in  leukoma,  691 
tears  of,  317 
teratoid  tumors  of,  309 
transplantation  of,  282 
transverse  calcareous  band  of,  300 
trellised  opacity  of,  298 
tuberculosis  of,  270 
tumors  of,  307 
ulcers  of,  257,  263 

absorption,  264 

acute  serpiginous,  265 

annular,  268 

atheromatous,  280 

chronic  serpiginous,  268 

circular,  268 

conditions  associated  with,  277 

creeping,  265,  268 

deep,  264 

dendriform,  269 

dionin  in,  274 

excavated,  264 

exhaustion,  269 

faceted,  264 

from    diseases   of   nasal   accessory 
sinuses,  647 

gouged-out,  264 

indolent,  264 

infected,  265 
causes  of,  266 
marginal,  267 

internal.  280,  310 

marginal,  267 
ring,  268 

Mooren's,  268 

prognosis,  270 

purulent,  264 

reparative,  264 

results  of,  278 

ring,  269 

serum  treatment.  274 

shallow  central,  264 

simple,  264 

sloughing,  265 
causes  of,  266 

small  central,  264 

spreading,  treatment,  272 

subconjunctival  injections,  275 

thermotherapv  in,  275 

treatment,  270,  274 
constitutional,  277 
of  associated  conditions.  277 
results  of,  281 

tuberculous,  270 
ulcus  rodens  of,  268 
variolar  abscess  of,  267 
vascularization  of,  287 
vibration  massage  of,  281 
width  of,  51 
wounds  of,  305 
zonular  opacity  of,  300 
Corneal     complications     in     pulsating 

exophthalmos,  640 
image,  size  of,  95 
incisions  in  extraction  of  cataract,  726 


Corneal  loupe,  52 

microscope,  52 

opacities,  myopia  from,  134 
striate  clearing  of,  282 

pits,  302 

staphyloma,  278 

suture,  Kalt's,  738 
Corneitis,.     See  Keratitifi. 
Corneoscleral     trephining     in     chronic 
glaucoma,  423 
in  glaucoma,  421 
in  retinitis  pigmentosa,  489 
Cornu  cutaneum  of  eyelids,  181 
Corpora  geniculata,  565 

quadrigemina.  565 
tumor  of,  523 
Corpus  callosum,  puncture  of,  in  optic 

neuritis,  527 
Corrosive  sublimate,  177,  214,  654,  732 
Couching  for  cataract,  722 
Counterfeited  bhndness,  92 
Cover  test  of  ocular  muscles,  74 
Cowan's  axis  finder,  164 
Crab-Uce  in  eyelashes,  178 
Cramp,  convergence,  609 

of  eyelids,  189 
Cramptons  ophthalmoscope,  96 
Crede's     method     for     prevention     of 
ophthalmia  neonatorum,  213 

silver  drops,  213 
CreoUn,  206,  245,  628 
Crescents,  106 

atrophic,  384 

congenital  inferior,  517 

myopic,  137 

scleral.  385 

semi-atrophic,  384 
Critchett's    operation     in    sympathetic 
ophithalmitis,  368 

subconjunctival  tenotomy,  747 
Crossed  amblyopia,  556 

cylinder,  155 

fasciculus,  565 
Croton  chloral  hydrate,  174 
Croupous  conjunctivitis,  221 
Crj'ptophthalmos,  167 
Crystalline   lens.     See   also  Lens, 

crystalline. 
Culdesac,  new,  Uning,  with  epidermic 

graft,  680 
Cuneus,  566 

Cupping  of  nerve  head  in  glaucoma,  398 
Cuprocitrol,  239 
Curet,  chalazion,  660 

suction,  724 
Curettage  in  dacryocj'stitis,  758 
Curran's  operation,  706 
Curtin   and   Thomson's   operation   for 

retinal  detachment,  708 
Cutaneous  horns  of  eyelids,  181 
Cvanid  of  mercurv,  206.  207,  216,  238, 

239,  240,  271,  272,  275,  293,  295,  304, 

305,   336,   339,   354,   380,   444,   494, 

689,  740 
Cyanopsia,  555 
Cyanosis  of  retina,  463 


790 


INDEX 


Cyanotic  polycythemia,  463 

Cyclitic  membrane,  459 

Cyclitis,    348.     See    also     Iridocyclitis. 

after  cataract  extraction,  741 

atrophy  of  eyeball  from,  349 

causes,  349 

chronic  plastic,  349 

with  discoloration  of  iris,  53 

heterochromic,  53 

pain    in,    348 

pathology,    349 

phthisis  bulbi  from,  349 

plastic,  348,  349 

prognosis,  349 

purulent,  349 

serous,  348,  349 

symptoms,  348 

treatment,  349 

with  disease  of  vitreous,  352 
Cyclodialysis,  707 

in  glaucoma,  421,  423 
Cyclophoria,  74,  610,  614 

test  of,  78 
Cyclopia,  630 
Cycloplegia,  595 

Cycloplegics,  123.     See  also  Mydriatics. 
Cylinder,  crossed,  155 
Cylindric  lenses,  30 

distortion  of  objects  by,  162 
Cylindroma  of  eyelids,  183 
Cynamic  acid,  689 
Cysticercus  cellulosse  in  vitreous,  458 

in  anterior  chamber,  347 

in  iris,  344 

subretinal,  512 
Cystitome,   728 

Cystoid  cicatrix  after  cataract  extrac- 
tion, 741 
after  iridectomy  in  glaucoma,  422 
Cystoma,  epithelial,  of  conjunctiva,  251 
Cysts,  dermoid,  of  eyelids,   196 

Meibomian,  182.     See  also  Chalazion. 
removal  of,  660 

of   angle   of   anterior   chamber,    347 

of  conjunctiva,  250,  251 

of  cornea,  307 

of  eyelids,  180 

of  iris,  326,  344 

of  orint,  636 
removal,  719 

of  prolacrinial  sac,  624 

of  retina,  512 

of  retinal  (epithelium,  344 

of  sclera,  316 

orl)it()pal[)ol)ral,  630 

pearl-like  tumor  of,  344 

retention,  of  Kweat-ghuuls,  196 

sebaceous,  of  eyelids,  196 

DACRYO-adenitis,  620 

acute,  620 
chronic,  620 
nuitastatic,  620 
noii-su|)puralive,  ()20 
suppurative,  620 
sypliilitic,  tVJl 


Dacryo-adenitis,  treatment,  620 

tuberculous,  620 
Dacryocystitis,  623 

acut€,"623 

blennorrhoica,  623 

catarrhaUs,  623 

curettage  in,  758 

from    diseases    of    nasal    accessory 
sinuses,  649 

of  infants,  624 
treatment,  628 

phlegm  onosa,  623 
Dacryocvstorhinostomia,  761 
Dacryoliths,  621,  622 
Dacryops,  621 
Dalr\Tn pie's  sign  in  exophthalmic  goiter, 

642 
Dark-adaptation,  68 
D'Artha's   method   of   blepharoplasty, 

678 
Day-bhndness,  559 
Deep  keratitis,  295 

Degeneration   of   conjunctiva,    colloid, 
248 
hyaline,  248 

of  cornea,  family  punctate,  298 
Delimitation  of  scotomas,  89 
Dehrium  after  cataract  extraction,  743 
Demodex  foUiculorum,  177 
Dendriform  ulcers,  269 
Dennett's  method  of  numbering  prisms, 

19 
Depressing  for  cataract,  722 
Depression,  572,  573 
Dermic  graft,  679 

Dermo-epithelioma  of  conjunctiva,  251 
Dermogenetic  cataract,  434 
Dermoid  cysts  of  eyelids,  196 

tumor  of  cornea,  308 
Descemetitis,  294,  349 

with  choroiditis,  377 
Descenict's     membrane,     fissures     in, 

in  hydrophthalmos,  426 
Descending  neuritis,  519,  524 
DeSchweinitz's     enucleation     method, 

710 
Desiccating  powders,  174 
Desiccation,   electric,   in   carcinoma  of 
evelids,  187 

keratitis  of,  284 
Detachment  of  choroid,  395 

of  vitreous,  459 
Deutsclunann's  serum,  275 
Deviating  eye,  576 
Deviation,  angle  of,  19 

congenital,  .')'.)  1 

conjugate,  594 

horizontal,  Maddox  rod  test  for.  79, 
80 

vertical,  Maddox  rod  te.><t  for,  79,  80 
DevioMii'tcrs,  ()t)2 
DieWCcUcr     internal     sclerotomy.     700 

iritlotoniy,  697 

operation  for  staphyloina,  691 

pnotonietric  types,  tiS 

pince-ciseaux,  (')97 


I 


I 


INDEX 


791 


Diabetes,  amblj^opia  from,  551 

mj'opia  in,  135 
Diabetic  coma,  eyeball  in,  396 

iritis,  338 

retinitis,  478 
Diachylon,  178 
Dichloramin-T,  246,  712 
Did\Tnium  glass,  560 
Dieffenbach's  method  of  blepharoplasty, 

677 
Diffuse  interstitial  keratitis,  287 
DigitaUs,  278,  461,  541,  554 
Diktyoma  of  ciliary  body,  358 
Dilatation  of  pupil,  61 
paradoxic,  65,  66 
Dilatation-reflex  of  pupil,  57 
Dilatator  paralj'sis,  63 

pupillse,  58 

contraction  of,  61 
Dimitry's  modification  of  Mules'  opera- 
tion, 713 
Dimness  of  vision,  545 
Dionin,  216.  219,  239,  240,  258,  261, 

270,  271,  274,  281,  284,  286,  293,  295, 

296,   297,   298,   300,   304,   312,   314, 

335,  338,  339,  354,  367,  380,  419,  425, 

444,  494,  657,  658,  709,  724,  741 
Diopter,  29 

Dioptric  apparatus,  126 
Diphtheria  antitoxin,  222,  224 

streptococcus,  of  conjunctiva,  222 
Diphtheritic  conjuncti\atis,  223 
Diplobacillary  keratitis,  205 

ulcer,  266,  276 
Diplobacillus,  200,  266 

conjunctivitis,  204 

of  Morax-Axenfeld,  205,  266 
Diplococcus,  222 

Frankel-Weichselbaum ,  203 

intracellularis  meningitidis,  452 
Diplopia  after  operation,  600 

anomalous,  600 

complete  crossed,  586 

crossed,  579,  581 

heteronjTnous,  579,  581 

homonymous,  577,  581 

horizontal,  581 

in  paralytic  strabismus,  580 

lateral,  581 
crossed,  582 
homonjTnous,  581 

monocular,  618 
in  cataract,  430 

paradoxic,  600 

simple,  577,  581 

table    of,    in    ocular    paralysis,    588 

test  for  mahngering,  557 

vertical,  581 

crossed,  583,  584 
homonjTnous,  584,  585 
Direct  light-reflex  of  pupil,  55,  59,  60 

method  of  ophthalmoscopy,  97,  101. 
See  also  Ophthal  moscopy,  direct 
method. 

vision,  81 
for  colors,  72 


Directly  periodic  divergent  squint,  578 
Discission  for  after-cataract,  746 
glaucoma  after,  746 

for  cataract,  722 
Discoloration     of     iris     with     chronic 

cycUtis,  53 
Dislocation    of    crystalHne    lens,    448 

of  eyeball,  650 
Disseminated  choroiditis,  376 

mihary  tubercle  of  iris,  340 

sclerosis,  538 
Distichiasis,  167,  192 

complete,  operation  for,  667 

congenital,  168 
Distortion     of     objects     bj'     cyUndric 

lenses,  162 
Divergence  of  rays,  21 

paralysis,  595 
Divergence-excess  in  heterophoria,  611 
Divergence-insuflaciency        in    hetero- 
phoria, 610 
Divergent  rays,  22 

squint,  578 

strabismus,  577,  583,  586.     See  also 
Strabismus,  divergent. 
Dobell's  solution.  262.  628 
Donovan's  solution,  354 
Double  perforation  of  ej'e,  318 
Do\Tie's  cataract,  440 
Drainage  of  lacrimal  sac,  761 
Dressings,  654 

Drugs,  amblyopia  from  abuse  of,  552 
Drusen  in  optic  nerve,  543 
Drusenbildungen,  544 
Dry  catarrh,  199 

Duane's    diagnostic    table    in    oculo- 
motor paralysis,  588 

method  of  testing  range   of  accom- 
modation, 39,  40 

tenotomj^  of  inferior  oblique,   748 
Dubois    and    Lerov    ophthalmometer, 

116 
Duboisin,  123,  124,  244,  334 
Dust,  choroidal,  393 
Dynamic  skiametry,  123 

strabismus,  73 
Dyschromatopsia,  546,  547 
Dystrophj-  of  cornea,  epithelial,  300 

Eau  de  cologne,  177 
Ecch\Tnosis  of  conjunctiva,  249 

of  eyelids,  197 
EcUpse  blindness,  509 
Ectasia,  marginal,  299 

of  sclera,  315 

sclerae,  313 

total,  316 
Ectopia  lentis,  448 
hereditary,  448 
Ectropion,  167,  194 

acute,  194 

Adams'  operation  for,  670 

chronic,  194 

epidermic  grafts  for  correction  of,  673 

epithelial  outlay  for  correction  of,  675 
overlay     for     correction     of,     673 


792 


INDEX 


Ectropion,  galvanocauterv  puncture  in, 
672 
Gillies'  operation  for,  675 
Kuhnt-Miiiler  operation  for,  670 
Kuhnt-Szymanowski  operation  for, 

670 
of  urea,  congenital,  326 
operations  for,  670 
paralytic,  IDO 
senile,  operation  for,  670 
Snellen's  suture  operation  for, 671 
Wharton  Jones'  operation  for,  672 
Eczema,  marginal,  175 
of  conjunctiva,  224 
of  cornea,  259 
of  eyelids,  172 
on  lid-border,  175 
pustular  form,  176 
seborrhoicum,  177 
solitary  form,  175 
superficial  form,    175 
Edema,  angioneurotic,  of  eyelid,  169 
malignant,  of  eyelid,  170 
of  conjunctiva,  250 

angioneurotic,  250 
of  eyelids,  169,  197 

from    diseases   of   nasal   accessory 

sinuses,  647 
solid,  169 
of  optic  nerve,  518 
of  retina,  466,  506,  522 
Educative  treatment  in  strabismus,  603 
Efferent  path,  59 

pupillary  paths,  58,  60 
Egyptian  conjunctivitis,  243 

ophthalmia,  229 
Electric    desiccation    in    carcinoma   of 
eyehds,  187 
ophthalmia,  559 
ophthalmoscope,  96,  101 
retinitis,  509 
Electricity,  190 
in  cataract,  435 
in  paralytic  strabismus,  592 
Electric-light  perimeter,  84 
Electrolysis,  227,  240,  667 
for  nevi  of  eyelids,  180 
in  angioma,  180 
in  corneal  opacities,  281 
in  trichiasis,  667 
in  xanthelasma,  182 
Electrolytic  i)unctures,  sclerotomy  com- 
bined wit  h,  for  r(.'t  inal  detachment, 708 
Electromagnet,  7U) 
Elephantiasis  arabum  of  eyelids,  ISS 
lymphangiodes,  KiO 
telangiectodes  of  evelich 
Elevation,  572,  573 
Elevator,  lid-,  728 
Elliot's  operation,  703 
after-treatment,  701 
application  of  Irepliiiic, 
causes  of  failure  in,  705 
coriiplicalions  arising  in,  705 
flaj)  in,  703 
in  gliuicotiiM,   123 


188 


rot 


Elliot's  operation,  indications  for,  705 
installation  of  drops,  704 
modifications  of,  704 
quadrant  of  eye  selected,  703 
toilet  of  wound,  704 
Elschnig's  method  of  local   anesthesia, 
659 

operation  for  ptosis,  661 
Embolic  panophthalmitis,  472 
Embolism  of  central  artery  of    retina, 

501.     See    also  Retina,  central  artery 

of,  obstruction  of. 
Embryotoxon,  309,  323 
Emetin,  355 
Emmetropia,  22,  126 

definition,  126 

retinal  image  in,  34 

skiascopy  in,  120 
Emphysema  of  conjunctiva,  250 

of  eyehds,  197 
Empyema  of  antrum  of  Highniore,  646 

of  frontal  sinus,  643 

of  sphenoid  sinus,  646 
Encanthis,  257 

functional,  257 

malignant,  258 

symptomatic,  257 
Encephalocele  of  orbit,  639 
Enchondroma  of  choroid,  392 

of  tarsus,  181 
Endameba  buccalis,  355 
Endarteritis,  469 

syphihtic,  468,  469 
Endogenous  gonorrheal  keratitis,  221 

ophthalmitis,  472 
Endophthalmitis,  354,  385 

septica,  386 
Endothelioma,        interfascicular,        of 
choroid,  389 

of  conjunctiva,  253 

of  eyelids,  185 

of  orbit,  638 
Engorgement-edema  of  papilla,  518 
Enixanthos  glass,  560 
Enlargement  of  bhnd-spot,  648 
Knophthalmos,  92,  651 
Kntozoa  in  retina,  458 

in  vitreous,  458 
Entropion,  167,  193 

Anagnostakis-IIotz  operation  for,  669 

Burow's  operation  for,  669 

forceps,  668 

galvanocautery  puncture  in.  672 

operations  for,  668 
Emicleation  for  sarcoma  of  ciioroiil,  392 

in  hemorrhagic  glaucoma,  425 

in  supi)urative  choroiditis,  3S7 

in  svini)atlieti<'  ophtiialmitis,  366,  367 

of  eyeball,  709 
accitlcnts  in,  710 
aftcr-treatnuMit,  71 1 
Hdiinct's  metliod,  709 
l)e  Schweinitz's  nietluxl,  71(1 
fat      imi)lanta(ion      into       Tenon's 

cai)sule  jifter,  715 
I'ergus'  method,  710 


I 


INDEX 


793 


Enucleation    of    eyeball,    hemorrhage 
after,  710,  711 
implantation  of  artificial  globe  in 
Tenon's  capsule  after,  714 
of  cartilage  after,  714 
in  gUoma,  512 
Krauss'  method,  710 
perforation  of  sclera  in,  711 
remote,   implantation   of   glass   or 

gold  ball  after,  ^15 
Schmidt's  method,  710 
Smith's    (Priestley)    method,    710 
Suker's  method,  709 
Vienna  method,  709 
Eosin,  51 

Epaulet-like  swelling  of  cornea,  289 
Ephedrin  homatropin,  125 
Ephidrosis,  196 
Epibulbar  conjunctivitis,  gonorrheal,202 

sarcoma  of  conjunctiva,  253 
Epicanthus,  168 

external,  168 
Epidemic  catarrh,  207 
conjunctival  catarrh,  202 
conjunctivitis,  catarrhal,  207 
Epidermic  graft,  679 

for  correction  of  ectropion,  673 
lining  a  new  culdesac  with,  680 
Epilation  of  eyelashes,  659 
Epiphora,  190,  622 
treatment  of,  622 
Episcleral  nodes,  311 
Episcleritis,  311 
cause,  311 

fugacious  periodic,  312 
treatment,  312 
Epistaxis,    artificial,    before    operation 

for  glaucoma,  421 
Epitarsus,  168 
Epithehal  choroiditis,  374 
cystoma  of  conjunctiva,  251 
dystrophy  of  cornea,  200 
hyperplasia  of  ciUary  body,  358 
inclusions,  216 

outlay  for  correction  of  ectropion,  675 
overlay  for  correction  of  ectropion,  673 
Epithehoma,  contagious,  196 
of  conjunctiva,  252 
of  eyelids,  183,  184 
of  lacrimal  sac,  626 
of  orbit,  639 
Equator  of  eye,  146 
Equilibrium  test  of  ocular  muscles,  75 
Erect   image,    27,    97,    101.     See    also 

Ophthalmoscopy,  direct  method.    ■ 
Ergotism  and  cataract,  435 
Erisophake,  744  ' 
Erosions  of  cornea,  304 

relapsing,  305 
Erysipelas  of  eyehds,  170 
Erythema  of  eyehds,   169 
Erythropsia,  560 

Eserin,  41,  124,  219,  244,  271,  273,  274, 
282,  290,  300,  303,  312,  345,  354, 
412,  419,  421,  423,  426,  618,  659, 
700,  729,  743,  745' 


Eserin  in  glaucoma,  418,  419,  420 
iritis,  341 
salicylate,  418 
sulphate,  418 
Esophoria,  74,  610 
spasmodic,  596 
with  myopia,  145 
Esotropia,  74,  576,  579,  610.    See  also 

Strabismus,  convergent. 
Essence  of  anaphylaxis,  366 
Essential  edemas  of  eyehd,  169 
phthisis  bulbi,  396 
shrinking  of  conjunctiva,  256 
Esser's   epithelial   inlay  for    cicatricia 

orbital  socket,  680 
Ether,  17,  654,  655,  656 
Ethmoid  sinus,  disease  of,  644 
mucocele  of,  645 
retention-cyst  of,  644 
Ethmoiditis,  645 
Ethyl  chlorid,  656 
Ethvlate  of  sodium,  252 
Ethylhydrocuprein,  207,  276,  740 

amblyopia,  553 
Eucain,  656 
Euphos  glass,  560 
Euphthalmin,  111,  125,  328,  430 
Europhen,  276 

Everbusch's  operation  for  ptosis,  661 
Eversion  of  eyehd,  48,  49,  194 
Evisceration  in  suppurative  choroiditis, 
388 
of  eyeball,  712 

Gifford's    method,    713 
Lister's  substitute,  713 
simple,  713 

with  insertion  of  artificial  vitreous, 
713 
Examination,  external,  of  eye,  47 

of  patient,  47 
Exanthematous  conjunctivitis,  201,  207 
eruptions  on  eyeUd,  172 
keratitis,  267 
Excessive  accommodation,  41 
Excision,  combined,  for  trachoma,  688 
of  lacrimal  sac,  758 
of  pterygium,  683 

of  retrotarsal  fold  in  trachoma,  687 
Exciting  eye,  359 
Exenteration  of  orbit,  719 
Exhaustion  ulcer,  269 
Exophoria,  74,  610,  611 
Exophthalmic  goiter,  641 
corneal  changes  in,  642 
nature  of,  642 

ophthalmoscopic  changes  in,  642 
signs  in,  642 
treatment,    643 
Exophthalmometer,  92 
Exophthalmos,  92,  630,  651 
intermittent,  651 
pulsating,  636,  640 
Exostoses  of  orbit,  639 
operation  for,  720 
Exotropia,     74,     577,     611.     See     also 
Strabisinus,  divergent. 


794 


INDEX 


Expansile  pulse  of  retinal  arteries,    106 
Exposure  keratitis,  190 
Expression  for  trachoma,  686 
External  epicanthus,  168 
examination  of  eye,  47 
rectus,  572 

advancement  of,  752 

in  myopia,  142 

paralysis  of,  581 
Extinction  test  for  scotomas,  89 
Extirpation  of  lacrimal  gland,  629,  760 

sac,  629 
of  palpebral  portion  of  lacrimal  gland, 

761 
of  tarsus  for  trachoma,  689 
of  whole  contents  of  orbit,  719 
Extorsion,  572,  573 
Extract  of  hamamelis,  170 
Extraction  of  cataract,  722 

accidents,  734 

acuteness  of  vision  in,  447 

after-treatment,  733 

amount  of  vision  after,  447 

Angelucci's  method,  744 

anomalies  in  healing  after,  738 

astigmatism  after,  447 

Barraquer's  method,  744 

bulging  cicatrix  after,  741 

by  discission,  722 

Cfhandler's  method,  744 

choice  of  operation  for,  744 

combined,  726 

corneal  incisions  in,  726 

corneal  opacities  after,  742 

cyclitis  after,  741 

cystoid  cicatrix  after,  741 

delayed  healing  after,  743 

restoration  of  anterior  chamber 

after,  743 
union  after,  743 

delirium  after,  743 

dressings  for,  728,  732 

expulsive  intra-ocular  hemorrhage 
after,  739 

filamentous  keratitis  after,  742 

filtration  cheniosis  of  conjunctiva 
aft«r,  743 

fifth  stage,  731 

first  stage,  729 

fourtli  stage,    730 

gelatinous  exudate  after,  741 

glasses  after,  447 

glaucoma  after,  741 

hemorrhage  after,  739 

lier|)('s  of  cornea  after,  742 

in  capsule,  WFy 

liidian  iiietliod,  in  capsule,  735 

insanity  after,  713 

instruments  for,  7'JS 

iridocvclitis  after,  7  JO 

iritis  after,  710 

irrigation  of  anterior  ciianiher  in, 
731 

ketalitis  after.  742 

Knapp's  CAriioId)  method,  738 

I-ehrun's  met  hod,  72(5 


Extraction    of    cataract,   lenses   after, 
447 

Liebreich's  method,  726 

linear,  724 

needle  operation  for,  722 

open  treatment  after,  733 

Pagenstecher's  method,  726 

pain  after,  738 

position  of  patient  for,  728 

prehminary      capsulotomv      with, 
744 
iridectomy  with,  744 

preparation  of  eye,  726 
of  patient  for,  726 

prolapse  of  iris  after,  742 

ring  abscess  after,  740 

second  stage,  730 

Smith's  (Col.  Henry)  operation  for, 
735 

solution  operation  for,  722 

solutions  for,  72S 

spongy  exudate  after,  741 

striated  keratitis  after,  742 

subconjunctival,  738 

suction  method,  724 

suppuration  of  wound  after,  739 

Teale's  method,  724 

third  stage,  730 

toilet  of  wound  after,  731 

unilateral,  446 

vision  after,  447 

with  iridectomy,  726 

without  capsulotomy,  726 
iridectomy,  725.  732 
Extrapapillary  coloboma,  370 
Exudative  retinitis,  499 
Eye,  aberration  of,  122 
amaurotic.  545 

cat's.  3S5.  510 
amotr()i)ic.  127 
ammonia  burns  of,  306 
artificial,  711 

insertion  of,  711 

reformed,  712 
astigmatic  form  of  image  in,  147 
axis  of,  145 
black,  197 
blear,  176 
blood-vessels  of,  105 

distribution  of,  IOC) 
carbolic  acid  burns  of,  300 
copper  in.  319 
deviating,  576 
direct  insju'ction  of,  47 
double  perforation  of,  318 
ennnetropic,  126 
e(iuator  of.  146 
examination  of.  external,   17 
exciting,  ;{59 
far  point  of.  37 
fixing.  576 

occlusion    of,    in    str:il>i>nius.    603 
foreign  bodies  in.  318 

metallic,  removal  of,  716 
removal  of,  319 
functional  testing  of,  47 


INDEX 


795 


Eye,  glass  in,  319 
hot,  312 

hypertonia  of,  396 
hypotonj'  of,  396 
inspection  of,  direct,  47 
meridians  of,  146 
mobility  of,  73 

muscles.     See  Ocular  ynuscles. 
near  point  of,  37,  38 
neglected,  598 
pigmentation  of,  hematogenous,  322 

xenogenous,  322 
pink,  202 
poles  of,  146 
position  of,  92 
preparation  of,  for  cataract  extraction, 

726  ■ 
shattered,  317 
shooting,  550 
speculum,  693 
squinting,  576 
strength  of,  in  myopia,  138 
stretching,  375 
sjTnpathizing,  359 
tapeworm  larvse  in,  458,  459 
weak,  175 
EyebaU,  accommodative  movement  of, 

574 
adherence  of  eyehd  to,  191 
anomaHes  of,  572 
associated  movements,  574 
atrophy  of,  349,  385,  396 
cohesion  of,  with  ej-eUds,  191 
concussion  of,  652 
congenital  anomalies  of,  630 
contusion  of,  652 
convergence  movement  of,  574 
diseases  of.  630 
dislocation  of,  650 
elongation  of,  in  myopia,  135 
enucleation  of,  709 

accidents  in,  710 

after-treatment,  711 

Bonnet's  method,  709 

De  Schweinitz's  method,  710 

fat     implantation     into     Tenon's 
capsule  after,  715 

Fergus'  method,  710 

hemorrhage  after,  710,  711 

implantation  of  artificial  globe  in 
Tenon's  capsule  after,  714 
of  cartilage  after,  714 

Krauss'  method,  710 

perforation  of  sclera  in,  711 

remote,   implantation   of   glass   or 
gold  ball  after,  715 

Schmidt's  method,  710 

Smith's  (Priestlev)  method,  710 

Suker's  method,  709 

Vienna  method,  709 
evisceration  of.  712 

Gifford's  method,  713 

Lister's  substitute,  713 

simple,  713 

with  insertion  of  artificial  vitreous, 
713 


Eyeball,  foreign  bodies  in,  localization 
with  x-ray,  768 
removal,  709 

hardness  of,  in  glaucoma,  397 

immobility  of,  630 

in  diabetic  coma,  396 

massage  of,  in  chronic  glaucoma,  419 
in    obstruction    of   central   artery, 
505 

movements  of,  572 

retraction,    wth    congenital   defi- 
cieuc}'  of  abduction,  591 

obhque  movements  of,  573 

operations  on,  709 

primary  position  of,  573 

protrusion  of,  636,  637 

retraction  of,  651 

rotation  of,  around  casual  line,  573 

secondary  position  of,  573 

separation  of,  44 

shape  of,  strabismus  from,  599 

siderosis  of,  322 

sinking  of,  92 

steel  in,  318,  319,  768 

tenderness  of,  328 

tension  of,  90 

torsion  of,  573 

vertical  meridian,  573 

wheel-rotation  of,  573 

wounds  of,  316,  317 
Eye-glasses,  163-166 
Eyelashes,  epilation  of,  659 

pediculus  pubis  in,  178 

supplementary  incurved,  167 

trichophyton  tonsurans  in,  177 

turning  gray  of,  193 
Eyehd,  abscess  of,  170 

absence  of,  167 

adenoma  of,  181 

adherence  to  eyeball,  191 

alopecia  of,  193 

angioma  of,  180 

angiomegaly  of,  180 

angioneurotic  edema  of,  169 

anthrax  of,  170 

blastomj'cosis  of,  171 

burns  of,  198 
■   carcinoma  of,  183 

cavernous  growths  of,  180 

chromidrosis  of,  196 

cleft,  167 

cohesion  of,  167 
wnth  eyeball,  191 

coloboma  of,  167 

congenital  anomahes  of,  167 

comu  cutaneum  of,  181 

cramp  of,  189 

cutaneous  horns  of,  181 

cylindroma  of,  183 

cysts  of,  180  ^ 

dermoid  cysts  of,  196 

diseases  of,  167 

ecchymosis  of,  197 

eczema  of,  172 
border  of,  175 

edema  of,  169,  197.  630 


796 


INDEX 


Eyelid,  edema  of,  from  diseases  of  nasal 
accessory  sinuses,  647 
elephantiasis  of,  188 
emphysema  of,  197 
endothelioma  of,  185 
epithelioma  of,  183,  184 
ery.siijclas  of.  170 
ervthemu  of,  1(39 
eversion  of,  48,  49,  194 

of  edges  of,  167 
exanthematous  eruptions  of,  172 
fat  hernias  of,  181 
favus  of,  177 
fibroma  of,  181 
foreign  bodies  in,  197 
furuncle  of,  170 
glandular  carcinoma  of,  185 
granular,  229 
gumma  of,  179 
hemangiomas,  of,  180 
herpes  facialis  of,  174 

zoster  of,  173 
hives  of,  170 
hyperemia  of,  170 

of  border,  175 
hypertrophy  of,  179 
injuries  of,  196 
insufficiency  of,  242 
inversion  of,  193 

of  edges  of,  167 
lepra  of,  187 
lipoma  of,  181 
lupus  vulgaris  of,  183,  187 
lymphangiomas  of,  180 
lymphoma  of,  183 
malignant  edema  of,  170 

pustule  of,  170 
marginal  union  of,  167 
molluscum  fibrosum  of,  181 
neurofibromatosis  of.  181 
neuroma  of,  181 
nevi  of,  180 
noma  of,  170 
operations  on,  659 
papilloma  of,  179,  ISl 
partial  development,  1()7 
plastic  operations  on,  674 
|)ost variolous  ulcer  of,  172 
ptosis  of,  190 

Iil)oiiiat()sis  of,  181 
redness  (if.  630 
rhagudes  on,  179 
rodent  ulcer  of,  183 
sarcoid  of,  181 
sarcoma  of,  183 
sebaceous  cysts  of,  196 
seborrh(!H  of,  175 
spasm  of,  1S9,  190,  191 
spastic  ptosis  of.  1S9 
s|)orotrich(isis  of,  17S 
spreading  gangrene  of,  170 
supernumerary,  169 
swelling  of,  630 
syphihs  of,  178 
syphilitic  uh-ers  of,  187 
tertiary  ulcers  of,  179 


Eyelid,  tuberculosis  of,  187 

tumors  of,  179 

union  between  margins  of,  167 

urticaria  of,  170 

vaccine  vesicles  on,  172 

verruca  on,  179 

warts  on,  179 

wounds  of,  196 

xanthelasma  of,  181 

xanthoma  of,  181 

xeroderma  pigmentosum  of.  188 
Eve-strain,  126,  128,  148,  150,  372,  454, 

455,  521,  537 

False  cilia,  192 

Familial  chorioretinitis,  379 
glaucoma.  409 
Family  cerebral  degeneration  of  retina 

with  macular  changes,  514 
punctate  degeneration  of  cornea,  298 
Far  point  in  hyperopia,  129,  134 

in  myopia,  133 

of  convergence,  46 

of  eye,  37 
Fascicular  keratitis,  260 
Fasciculi.  565 
Fat  hernias  of  eyelids,  181 

implantation    into    Tenon's    capsule 

after  enucleation,  715 
Fatty  degeneration  of  vitreous,  454 
Favus  of  eyelids,  177 
Feeble  chromatic  sen.se,  69 
Fergus'  enucleation  method,  710 
operation,  703 

for  ptosis,  664 
Fetal  iritis,  324 
Fibers  of  Gratiolet,  566 
Fibrolysin,  227.  281,  456,  482 
Fibroma  of  antrum  of  Ilighmore,  647 
of  eyelids,  181 
of  limbus.  225 
Field  of  fixation,  575 
of  vision,  81 

abnormalities,  88 

amblyopia  of,  561 

oscillating,  463 

binocular,  86 

Hjerrum's  test  for,  82 

displacement  type,  462 

exhaustion  ty|)e,  463 

exhaustion-spiral  type,  463 

fatigu«!  restrictions  of.  561 

in  atrophy  of  o])tic  nerve,  532 

in  detachment  of  retina.  493 

in  obstruction  of  central  artery,  503 

in  optic  neuritis.  .520 

in   paralytic  straiiismus,   5S0,  582, 
583,  .584,  585,  5S() 

ii\  retinitis,  4t)5 

limits  of,  SI,  S2 

confrontation  methods  in.  81 

obscuration  of  <uie-iialf  of.  561 

recuperation-extension  t\pc.   Ki.i 

rel.ntive,  85 

shifting  type,  462 

unst.uiile  concentric,   lt>!< 


INDEX 


797 


Fieuzal  glass,  560 
Filamentous  keratitis,  300 

after  cataract  extraction,  742 
Filaria   sanguinis   hominis   in   anterior 
chamber,  347 
in  vitreous,  459 
Filtration  chemosis  of  conjunctiva  after 
extraction  of  cataract,  743 
scar  in  glaucoma,  423 
Fissures   in   Descemet's  membrane   in 

hydrophthalmos,  426 
Fistula,  buccal,  624 
capillary,  624 
congenital,  of  eyelid,  169 
internal,  of  lacrimal  sac,  624 
of  cornea,  281 
of  lacrimal  gland,  621 

sac,  624,  626 
of  orbit,  645,  648 
Fixation,  binocular,  574 
field  of,  575 
line  of,  41 
Fixing  eye,  576 

forceps,  693 
Flaps,     pedunculated,     for    repair     of 
displaced    eyelids    and    loss    of    lid 
substance,  675 
Flatness  of  cornea,  congenital  familial, 

310    - 
Flavine,  712,  714 
Flimmer-scotom,  561 
Fluctuation,  631 
Fluidity  of  vitreous,  456 
Fluorescein,  50,  249,  272,  285,  296,  361, 
690 
to  detect  corneal  abrasions,  50 
Focal  distance  of  lens,  28 
Foci,  conjugate,  24 
Focus  of  concave  lens,  25 
conjugate,  25 
principal,  25 
of  convex  lens,  23 
conjugate,  24 
principal,  23 
virtual,  24 
Follicles,  school,  228 
FolUcular  conjunctivitis,  228 
ophthalmia,  228 
trachoma,  233,  235 

non-inflammatory,  234 
Follicuhtis,  176 
FoUiculosis,  228 

of  conjunctivitis,  228 
Forceps,  capsule,  728 
cilium,  659 
entropion,  668 
fixing,  693 
iris,  curved,  693 
punch,  sclerectomy  with,  702 
Reese's,  754 
Foreign  bodies  in  anterior  chamber,  347 
in  choroid,  394 
in  conjunctiva,  256 
in  eyelids,  197 
in  iris,  345 
in  lens,  450 


Foreign  bodies  in  sclera,  318 
in  vitreous,  320,  457 
localization  of,  with  x-ray,  320,  768 
removal  of,  319,  709,  716 
routes  of  attraction  by  magnet,  321 

protein  in  eve  infections,  277 
Formaldehyd,'216,  272,  627 
Formahn,  740 
Formol,  715 
Form-sense,  67 
Fourth  nerve,  573.     See  also  Trochlear 

nerve. 
Fovea,  42 

centralis,  44,  108 

vicarious,  600 
Foveal  reflex,  108 
Fowler's  solution,  189 
Fox's  implantation  operation,  715 
Frankel-Weichselbaum  diplococcus, 
203,  266,  274 

pneumococci,  386 
Franklin  bifocal  lenses,  166 
Free    dermic    (whole-skin)    grafts    for 

correction  of  ectropion,  674 
Fricke's  method  of  blepharoplasty,  678 
Frontal  sinus,  disease  of,  643 
treatment,  644 
empyema  of,  643 
mucocele  of,  643 
osteoma  of,  643 

sinusitis,  643 
Frost-Lang  operation  of  implantation, 

714 
Fruehjahr's  catarrh,  225 
Fugacious  amaurosis,  partial,  561 

periodic  episcleritis,  312 
Fukala's  method  of  removal  of  lens  in 

high  myopia,  724 
Fulguration,  187 
Functional  night-blindness,  558 

testing,  47 
Fundus,  albinotic.  111 

lymphorrhagia  of,  509 

tessellated.  111 
Fundus  hsematodes,  511 
Furnace-workers'  cataract,  435 
Furrow-keratitis,  269,  299 
Furuncle  of  eyehd,  170 
Fusion,  575 

facultv    in    concomitant   strabismus, 
598 

Gaillard's  suture  for  entropion,   668 

Gallicin,  225 

Galvanic  current  in  vitreous  opacities, 

454 
Galvanism  in  corneal  scars,  281 

in  heterophoria,  613 

in  optic  atrophy,  536 

in  retinitis  pigmentosa,  489 

in  uveitis,  355 
Galvanocautery.     See  Actual  cautery. 
Gamma  angle,  41,  42,  138 
Gangrene,  spreading,  of  eyelid,  170 
Ganio  Pinto  operation,  274 
Gas  bacillus  infection  of  orbit,  650 


798 


INDEX 


Gas,  lachrimatory,  effects  of,  245 
mustard,  effects  of,  245 
phosgene,  effects  of,  245 
poisonous,  conjunctivitis  from,  245 
Gelatinous  exudate   after  cataract  ex- 
traction, 741 
trachoma,  235 
Gelsemium,  189 
Gerontoxon,  301 
Gifford-Galassi  reflex,  57 
Gifford's  method  of  evisceration,  712 
modification  of  Kronlein's  resection 
of    temporal    wall    of    orbit,    722 
Gillet   de   Grandmont's   operation   for 

ptosis,  661 
Gillies"  epithelial  overlay  for  correction 
of  ectropion,  673 
operation  for  ectropion,  675 
Gittrige  keratitis,  298 
Glandular  carcinoma  of  eyelids,  185 
Glass,  didymium,  560 
enixanthos,  560 
euphos,  560 
fieuzal,  560 
in  eye,  319 
Glaucoma,  397 
absolute,  opticociliary  neurotomy  in, 
423 
state,  407 
accommodation  in,  402 
acute,  173,  378,  406,  429 
cataract  in,  429 
congestive,  397,  406 
inflammatory,  397 
iridectomy  in,  420,  421 
seasons  and,  410 
after  cataract  extraction,  741 
after  discission  for  cataract,  746 
amplitude  of  accommodation  in,  402 
anterior,  415 

chamber  in,  398 
aqueous  in,  398 
arteries  in,  401 

artificial  epistaxis  before  operation 
for,  421 
Bjer rum's  scotoma  in,  404 
causes,  409 

central  visual  acuteness  in,  401 
chronic,  408 

blood-pressure  in,  409 

cataract  and,  418 

causes,  409 

congestive,  397,  407 

corneoscleral    trephining    in,    421, 

423 
cyclodialysis  in,  421,  423 
diagnosiH,  417 
I'Mliott's  operation,  423 
Heine's  i)|)(!rati()M  in,   \2'A 
Herbert's     wcdge-i.sdlatiou     opera- 
tion for,  423 
heredity  in,  409 

Holtli's  punch  ()i)eratioii  in,   123 
iiidoelcisis  in,  423 
indotasis  in,  423 
intra-ocular  tension  ami,   115 


Glaucoma,  chronic,  iridectomy  for,  419, 
420,  421,  422 

iris  adhesion  in,  412,  417 

Lagrange's  operation,  423 

light-sense  in,  41S 

lymphatic  obstruction  and,  413 

massage  of  eyeball  in,  419 

non-congestive,  397 
miotics  in,  419 

of  both  eyes,  408 

pathogenesis,  410 

pathology,  410 

prognosis,  418 

retention  theory  of,  412 

sclerotomy  in,  421 

sclerectomy  with  punch  forceps  in, 
423 

sex  in,  409,  410 

simple,  408 

treatment,  418 
colored  vision  in,  560 
comphcated,  425 
congenitum,  426 
conjunctival  vessels  in,  398 
cornea  in,  398 
corneal  sensibility  in,  401 
corneoscleral  trephining  in,  421,  423 
cupping  of  nerve  head  in,  398 
cystoid  cicatrix  in,  422 

after  operation  for,  422 
dilatation  of  pupil  in,  61 
disposition  toward,  416 
Elhott's  operation  for,  423,  703 
enucleation  in,  424 
episcleral  vessels  in,  398 
excavation  of,  398 
excision  of  svmpathetic  ganglion  for, 

423 
familial,  409 

Fergus  operation  for,  703 
field  of  vision  in,  402,  404 
filtration  scar  in,  423 
from  hardening  of  sclera,  414 
from  indurative  scleritis,  414 
from  injury,  409 
from  mydriatics,  410,  413 
fulminans,  407 
halo  in,  398 

vision  in,  405 
hardness  of  eyeball  in,  397 
head  of  optic  nerve  in,  398 
hemorrliagie,  424 

enucleation  in,  425 

iridectomy  in,  425 
hereditary  tendency  in,  409 
high  myopia  with,  425 
intra-ocular  tension  in,  397 
iridectomy  in.  preventive,  421 

symptoms  after,    122 
iridescent  vision  in,   105 
iris  in,  :{U7,  39S 

adhesion  of,   1 12,   1 17 
irritalif.  397 
juvenile,   109 
light  dilTerenre  in,   1  IS 

sense  in,  401 


INDEX 


799 


Glaucoma,  loss  of  corneal  transparency 

in,  398 
malignant,  422 

treatment,  423 
mydriatic,  413 

test  in,  421 
nerve-head  in,  398 
non-congestive,  408 
operation  for,  418,  420 

artificial  epistaxis  before,  421 

hemorrhage  after,  421 
ophthalmic  migraine  in,  417 
pain  in,  401 
parallax  test  in,  399 
period  of  attack  in,  406 

of  incubation,  406 
peripheral  vision  in,  402 
primary,  397 
posterior,  415 
prodromal  stage  in,  406 
pupil  in,  397 

Quaghno's  operation  for,  699 
refractive  power  in,  402 
•  ring  in,  398 
rise  of  tension  in,  397 
Ronne's  nasal  step  in,  403,  403 
rupture  in,  spontaneous,  407 
scotomas  in,  404 
secondary,  173,  397,  424 

diagnosis,  424 

pathogenesis  of,  416 

treatment,  424 
Seidel's  sign  in,  405 
simple,  397 

chronic,  408 
simplex,  397,  408 

without  rise  of  tension,  408 
smallness  and,  409 
spontaneous  rupture  of,  407 
subacute,  407 

congestive,  397 
sympathectomy  for,  423 
sjrmptoms,  397 
traumatic,  409 
varieties  of,  397 
veins  in,  400 

vessel  pulsation  on  disk  in,  400 
vitreous  in,  398 
with  cataract,  425 
yellow  halo  in,  398 
Glaucomatous  attack,  406 
disposition,  416 
state,  406 
GUoma  endophytum,  510 
exophytum,  510 
of     retina,     510.     See     also    Retina, 

glioma  of. 
Globe.     See  Eyeball. 
Glycerin,  177,  195,  196,  239,  247,  256 

and  boric  acid,  444 
Glycerol  of  tannin,  243 
Glycosuric  amblyopia,  551 
Goiter,    exophthalmic,    641.     See   also 

Exophthalmic  goiter. 
Gonoblennorrhea   of   young  girls,    217 
Gonococcic  vaccine,  339 


Gonococcus,  230 

of  Xeisser,  209,  339 
Gonorrhea,  339 

Gonorrheal  conjuncti\'itis,  208,  217 
metastatic,  220 

epibulbar  conjunctivitis,  220 

iritis,  339 

keratitis,  endogenous,  221 

ophthalmia,  208 

rheumatic  iritis,  339 
Gouty  iritis,  337 

Gradenigo's  sjTnptom-complex,  589 
Graefe.     See  von  Graefe. 
Grafting  skin,  679 

Grafts,    epidermic,    for    correction    of 
ectropion,  673 

free  dermic  (whole-skin)  for  correc- 
tion of  ectropion,  674 
Granular  conjunctivitis,  229.     See  also 
Trachoma. 

lids,  229.     See  also  Trachoma. 
Gratiolet's  fibers,  566 
Grattage,  687 

in  trachoma,  240 
Graves'  disease,  641.     See  also  Exoph- 
thalmic goiter. 
Gray  cataract,  436 
Graying  of  eyelashes,  193 
Gray-red  disk,  530 
Greasy  tulle,  678 
Green  spot  in  myopia,  139 

\'ision,  560 
Green-blindness,  547 

complete,  69 
Green's   (Jr.)  method  of  curettage  in 

dacrj-ocystitis,  758 
Greenwood's  method  of  advancement, 

753 
Grill-Uke  keratitis,  298 

opacity  of  cornea,  298 
Grossmann's  theory  of  accommodation, 

37 
Gruebler's  fluorescein,  50 
Guaiacol  cacodylate,  689 
Gullstrand  ophthalmoscope,  96 
Gumma  of  ciUary  body,  356,  357 
precocious,  357 

of  eyehds,  179 

of  iris,  334,  356 
Gummatous  scleritis,  313 
Gunn's  dots,  109 
Guthrie-Saemisch  section,  690 

Schwenk's  modification,  690 
Guttate  iritis,  337 

opacities  of  cornea,  298 

Haab's  cerebral  cortex  reflex  of  pupil, 
57,  61 

giant  electromagnet,  716 

magnet,  321 

operation  for  foreign  bodies,  716 

pupillometer,  54 
Habit  chorea,  189 
Haitz's  stereoscopic  charts,  90 
Halo,  109 

vision  in  glaucoma,  405 


800 


INDEX 


Hanianielis,  197 

HaiKiicai)-prisms,  614 

Hanke's  bacillus,  307 

Hard  cataract,  extraction  of,  725 

Hardy  ophthalmometer,  116 

Harlan's  test  for  malingering,  557 

Hannan's  operation  for  ptosis,  661 

test  for  binocular  vision,  609 
Headache  in  astigmatism,  150 

in  heterophoria,  613 

in  h^'peropia,  129 
HeaUng,  delayed,  after  cataract  extrac- 
tion, 743 
Heine's  operation,  707 
in  glaucoma,  423 
Helmholtz'  ophthalmoscope,  95 

theory  of  accommodation,  36 
of  color-bhndness,  546 
Helmholtz-Young  theory  of  color  vision, 

547 
Hemangiomas  of  eyelids,  180 
Hematoma  of  optic  nerve-sheath,  549 
Hemeralopia,  558,  559 
Hemiablepsia,  564 

Hemiachromatopsia,  homonymous,  568 
Hemianopic  pupillary  inaction,  571 
Hemianopsia,  521,  661,  564 

absolute,  567 

altitudinal,  566 

binasal,  567 

bitemporal,  566 

central,  567 

complete,  567 

distant  symptoms  in,  569 

dividing  line  in,  568 

homonymous,  567 
double,  568 
left  lateral,  567 
right  lateral,  567 

horizontal,  566 

incomplete,  567 

iris  reaction  in,  571 

macular,  568 

of  migraine,  561 

I)eripheral,  566 

I)upil  in,  570 

relative,  568 

significance  of,  568 

transitorj',  561 

varieties,  566 

vertical,  566 

Wernicke's  symptom  in,  571 
Hemiopia,  5()4 

Heiniopic  pupillary  inaction,  65,  571 
Hemolytic  serum,  45(5 
Hciiiorrliage   after  enucleation   of  eye- 
ball, 710,  711 

after  section  of  iris,  421 

after  tenotomy,  719 

anterior     chamber,     after     cataract 
extraction,  739 

(•x|)ulsive  intra-ocular,  739 

from  conjunctiva,  250 

in  albuminuric  retinitis,  473 

in  retina,  494 
recurrent,  155 


Hemorrhage  in  retinitis,  465 

into  choroid,  395 

into  orbit,  650 

into  sheath  of  optic  nerve,  549 

into  vitreous,  455,  456 

preretinal,  495 

recurrent  subconjunctival,  249 

subhyaloid,  495 

with  retinitis,  467,  469 
Hemorrhagic    catarrhal   conjunctivitis, 
202 

central  retinochoroiditis,  380 

choroiditis,  384 

detachment  of  retina,  492 

glaucoma,  424 

retinitis,  472 
Hemostasis,  local,  659 
Herbert's  wedge-isolation  operation,  702 

for  glaucoma,  423 
Hereditary  detachment  of  retina,  492 

ectopia  lentis,  448 

nystagmus,  617 

optic  nerve  atrophy,  536 
neuritis,  536 

syphihtic  choroidoretinitis,  470 

tendency  in  glaucoma,  409 
Hering's  drop  test,  609 

theory  of  color  vision,  547 
Hernia,  fat,  of  eyelids,  181 
Herpes  facialis  of  eyelids,  174 
treatment,  174 

of  cornea,  285 

after  cataract  extraction,  742 
relapsing,  295 

zoster  cornea^,  173 
ophthalmicus,  173 
treatment,  174 
Herpetic  keratitis,  285 
Herschel  prism,  77 
Hertel's  telescopic  spectacles  in  myopia, 

143 
Hertzell's       ophthalmodiaphanoscopy, 

115 
Hess'  corneal  loupe,  52 

operation  for  ptosis,  664 
Heterochromia,  324 

iridis,  53 
Heterochromic  cyclitis,  53 
Heterophoria.  73,  74.  609 

acconimoilative,  610 

adverse  prisms  in,  614 

causes.  610 

central,  610 

classification  ui,  73,  74 

cobalt  glass  test  for,  79 

comitant,  610 

convergence-excess  in,  610 

convcrgencc-insufliciency  in,  611 

convergence-paralysis  in,  611 

cover  test  for,  71 

tlivergence-excess  in,  611 

divergence-insufliciency  in.  (110 

e(]uilibrium  test  for,  75 

general  symptoms.  613 

gymntistic  exerci.ses   with   prisms  in, 
611 


INDEX 


801 


Heterophoria,  headache  in,  613 

heterotropia  and,  difference  between, 
612 

method  of  examination  in,  613 

mixed  form,  610,  611 

muscle  exercises  in,  614 

muscular  asthenopia  in,  612 

ocular  symptoms,  612 

orthoptic  exercises  in,  616 

parallax  test  for,  74 

paretic,  610 

prescription  of  prisms  in,  615 

prism  tests  for,  75 

relative  frequency  of,  611 

screen  test  for,  74,  612 

spasmodic,  610 

stereoscopic  exercises  in,  616 

symptoms,  612 

tenotomy  in,  616 

thumb  exercises  in,  616 

treatment,  613 

varieties,  610 
Heterotropia,  73,  74,  576,  696.     See  also 

Strabismus. 
Hetol,  312,  689 

High-frequency  currents  in  glaucoma, 
420 
in  optic  nerve  atrophy,  536 
in  trachoma,  240 
in  xanthelasma,  182 
Hippus,  66 
Hives  of  eyehds,  170 
Holes  in  macula,  508,  509 
Holmes'  extirpationl  of  acrimal  gland, 

760 
Holmgren's    test    for    color-blindness, 

69 
Holocain,  91,  225,  227,  239,  245,  257, 
261,  270,  273,  274,  276,  284,  286, 
296,  297,  300,  303,  304,  305,  314, 
335,  338,  425,  657,  658,  690,  727, 
741,  742 
Holth's  iridocleisis,  706 

operation,  702 

punch  operation  in  glaucoma,  423 
Homatropin,   111,   123,   124,   174,  244, 

328,  421,  430 
Homonjonous  hemiachromatopsia,  568 

hemianopsia,  567 
Hook,  blunt,  693 

strabismus,  747 
Hordeolum,  171 

externum,  171 

internum,  171,  182 
Horizontal  hemianopsia,  566 

meridian,  32 
Horner's  syndrome,  63 
Horns,  cutaneous,  of  eyelids,  181 
Hot  eye,  312 

Hotz's     operation     for     artificial     lid- 
border,  667 
Hotz-Anagnostakis    operation    for    en- 
tropion, 669 
Howe's  apparatus  for  measuring  of  rela- 
tive  accommodation   at  near  point, 

46 
51 


Hunt-Tansley     operation     for     ptosis, 

662 
Hutchinson's  teeth,  290 
Hyahne  bodies  in  papilla,  543 

degeneration  of  conjunctiva,  248 
Hyalitis,  331,  451 

asteroid,  453 

punctata,  453 

treatment,  454 
Hyaloid  artery,  persistent,  459 

cataract,  446 

membrane,  hemorrhage  under,  495 
Hydrastin,  239 
Hydriodic    acid,    178,    262,    277,    444, 

454,  497,  506 
Hydrocephalus,  524 
Hydrochlorid  of  cocain,  125,  656 
Hydrogen  peroxid,  262,  628 
Hydrophthalmos,  426 

congenitus,  426 
Hyoscin,  124,  338 

in  iritis,  338 
Hyoscyamin,  123,  124,  244,  334,  613 
Hypersemia  marginalis,  175 

palpebraris,  199 
Hyperemia  of  choroid,  371.     See  also 
Choroid,  hyperemia  of. 

of  conjunctiva,  199 
causes,  199 
in  cataract,  429 
symptoms,  199 
treatment,  200 

of  eyelids,  170 

of  iris,  326 

of  lid-border,  175 

of  optic  nerve-head,   517.     See  also 
Optic  nerve,  head  of. 

of    retina,    460.      See    also     Retina, 
hyperemia  of. 
Hyperesophoria,  74 
Hyperesotropia,  74 
Hyperesthesia  of  retina,  461.     See  also 

Retina,  hyperesthesia  of. 
Hyperexophoria,  74 
Hyperexotropia,  74 
Hyperidrosis,  196 
Hypermetropia,  127.     See         also 

Hyperopia. 
Hyperopia,  23,  127 

absolute,  127 

accommodation  spasm  in,  128 

angle  gamma  in,  133 

aphakial,  127 

astigmatism  with,  152 

axial,  127 

blepharitis  in,  129 

causes,  127 

chalazia  in,  129 

choroidal  congestion  in,  129 

ciliary  body  in,  140 

coats  of  eye  in,  129 

congenital,  128 

congestion  of  retina  in,  129 

conjunctivitis  in,  129 

convergent  strabismus  in,  128 

correction  of,  129 


802 


INDEX 


Hyperopia,  correction  of,  in  children, 
132 
ophthalmoscope  for,  132 
skiascopy  for,  132 
with  test-types  and  trial  lenses,  130 

curvature,  127 

definition  of,  127 

degree  of,  131 

determination  of,  129 

facultative,  127 

far  point  in,  129,  134 

from  eyestrain,  128 

glasses  for,  132 

headache  in,  129 

hereditary,  128 

latent,  127 

lengthening  of  eye  from,  113 

manifest,  127 

ordering  of  glasses  in,  132 

retinal  image  in,  35 

senile,  128 

shortening  of  eye  from,  113 

skiascopy  in,  120 

styes  in,  129 

symptoms,  128 

total,  127 

transitory  increase  of,  135 

varieties,  127 
Hyperopic  disk,  518 
Hyperostoses    of   sphenoid    sinus,    646 
Hyperphoria,  74,  610,  611 

comitant,  611 

frequency,  611 

non-comitant,  611 
Hyperplasia,  epithehal,  of  ciliarv  bodv. 

358 
Hyperplastic    conjunctivitis,    periodic, 
225 

scleritis,  312 
Hypertension,  vascular,  41 
Hypertonia,  396 
Hypertrophic  l)lei)haritis,  176 
Hypertrophy  of  eyelids,  179 

of  lacrimal  gland,  620 

of  tarsus,  182 
Hypertropia,  74,  579,  611 
Hyphemia,  347 
Hypo|)hosphite  of  lime,  241 
Hypophosphites,  628 
Hypopituitarism,  41 
Hypoi)yon,  2ii5,  347 

keratitis,  26() 

autoserotherai)y  for,  274 
thermotlierapy  in,  276 

treatment,  273 
nvpotlialmic  bodv,  565 
Hypotony,  296,  396,  456,  65;{ 
Hysteric  visual  di.sturbances,  666 

IciiTirAUQAN,  216.  239 
Iclithyol,  174,  177,  207,  227,  2.39 
Idiocy,   amaurotic   family,    rhanges   at 

maculii  hitea  in,  513,  514 
Idiopathic  iritis,  340 
Ill-HUstaiiKMl  ncfoimuodatioii,   11 
liluminatioii,  ()hli(|ue,  51 


Image,  erect,  27 

form  of,  in  astigmatism,  147 
formation  of,  by  lens,  25 

in  direct  method,  98,  99 
inverted,  100,  114.     See  also  O phthal- 

nioscopy,  indirect  method. 
of  concave  lens,  27 
of  convex  lens,  27 
of  cornea,  94 
size  of,  95 
of     direct     and     indirect     methods, 

comparison  between,  99 
position  of,  26 
retinal,  in  ametropia,  35 

in  emmetropia,  34 
size  of,  26 

in  direct  method,  99 
in  indirect  method,  100 
Imagination  reflex  of  pupils,  57 
Imbalance,  609 
Immersion    method    in    conjunctivitis 

neonatorum,  215 
Immobility  of  eyeball,  630 

of  pupil,  63 
Implantation  cysts  of  conjunctiva,  251 
of  cornea,  309 
fat,     into     Tenon's     capsule,     after 

enucleation,  715 
of  artificial  globe  in  Tenon's  capsule 

after  enucleation,  714 
of    cartilage    after    enucleation,    714 
of  glass   or   gold   ball   after  remote 
enucleation,  715 
Inactivity,  reflex,  63 
Incidence,  angle  of,  18 
Incision    of    lacrimal     stricture,     758 

of  tis.sue  of  angle  of  iris,  700 
Inclusion  bodies,  204 
Inclusion-blennorrhea  of  newborn,  216 
Inclusions,  epithelial.  216 
Incomplete  ruptures  of  .sclera,  317 
Index  myopia,  135 
of  refraction,  17 
Indian  method  of  cataract  extraction, 

735 
Indirect    method    of    ophthalmoscopy, 
99,  114.     See  a\so  Ophthalmoscopy, 
indirect  method. 
reflex  action  of  pupil,  56,  60 
vision,  81 
Indocleisis  in  glaucoma,  423 
Indotasis  in  glaucoma,   123 
Indurative  scleritis,  glaucoma  from,  414 
Iiie(]uality  of  accommodation,  41 

of  pupils,  varying,  65 
Inertia  of  accommodation,  41 
infantile    ulceration     of    cornea     with 

xerosis  of  conjunctivji,  2S2 
Iiifecte<l  marginal  ulcer,  bacillus  of,  267 
Infectious  conjunctivitis,  211 
disease  iritis,  31 1 
necrotic  conjunctivitis,  208 
Infective  uveitis,  3(iO 
Inferior  <)bli(iue,  .573 
paralysis  of,  .5S4 
tenotomy  of,  748 


INDEX 


803 


Inferior  rectus,  572 

paralysis  of,  584 
Infiltration  anesthesia,  658 

of  cornea,  peripheral  annular,  306 
Inflammation    of    oculo-orbital    fascia, 
635 

of  tarsus,  188 
Inflammatory  theory  of  optic  neuritis, 

529 
Influenza  baciUus,  200 
conjunctivitis,  204 
Inherited  cataract,  435 

keratitis,  287 
Injuries  of  choroid,  394 

of  cihary  body,  356 

of  conjunctiva,  256 

of  cornea,  303 
obstetric,  307 

of  eyehds,  196 

of  iris,  345 

of  sclera,  316 
Innenpol  magnet,  321 
Innervation  in  concomitant  strabismus, 
598 

of  iris,  57,  58 
Insanity     after     cataract     extraction, 

743 
Inspection  of  cornea,  50 

of  eye,  direct,  47 
Instruments,  preparation  of,  654 
Insufficiency  of  accommodation,  41 

of  convergence,  577 

of  eyehds,  242 

of  ocular  muscles,  73 
Intercalary  staphyloma,  316 
Interior  ocular  muscles,   paralysis  of, 

595 
Intermittent  exophthalmos,  651 
Internal  capsule,  566 

fistula  of  lacrimal  sac,  624 

rectus,  572 

paralysis  of,  582 
tenotomy  of,  747 

sclerotomy,  700 

ulcer  of  cornea,  280 
International  test-types,  66 
Interstitial  keratitis,  287 

optic  neuritis,  530 

punctate  opacities  of  cornea,  299 
Intorsion,  572,  573 

Intra-ocular  optic  nerve  inflammation, 
518 

tension,  90 
Inversion  of  color-field,  556 

of  eyeUds,  193 
Inverted   image,    100,    114.     See    also 

Ophthalmoscopy,  indirect  method. 
Inward  torsion,  572 
lodid  of  cadmium.  620 

of  iron,  178,  262,  277,  633 

of  hthium,  354 

of  potassium,  171,  178,  225,  241,  256, 
258,  276,  294,  312,  314,  335,  339, 
354,  357,  372,  380,  444,  454,  456, 
466,  473,  497,  536,  541,  554,  592, 
594,   635,   637,   641,   741 


lodid  of  sajodin,  354 
of  silver,  239 

of  sodium,  354,  444,  454,  456,  473, 
497 
lodin,  261,  314,  318,  620,  639,  664,  678, 

714,  758 
lodin-vasogen,  276 

Iodoform,  216,  219,  224,  239,  256,  262, 
271,  272,  273,  321,  341,  628,  687, 
709,  733,  740 
amblyopia,  539,  553 
lodogallicin,  225 
lodol,  276 
Ionic  medication,  174 

for  blepharitis,  178 
Iontophoresis,  zinc,  for  purulent  kera- 
titis, 276 
Iridectomy,  281,  294,  303,  692 
broad  peripheral,  696 
combined  with  sclerectomy,  700 
comphcations  of,  697 
for  astigmatism,  156 
in  glaucoma,  419,  420,  421,  422 
in  hemorrhagic  glaucoma,  425 
in  sjonpathetic  ophthalmitis,  367 
in  uveitis,  355 

instruments  required  for,  692 
intra-ocular  hemorrhage  after,  496 
iridodialysis  after,  697 
narrow,  696 
optical,  444,  694 

point  of  entrance  of  keratome  in,  694 
position  of,  694 

of  operator,  694 
preliminary,   to   cataract  extraction, 

744         ■ 
sclerotomy    as    substitute    for,    423 
small,  696 

with  extraction  of  cataract,  726 
without  extraction  of  cataract,  725, 
732 
Irideremia,  326 
Iridescent  vision,  560 
in  glaucoma,  405 
Iridochoroiditis,  331,  352,  374,  386 
chronic  serous,  352 
plastic,  342 
serous,  360  i 

suppurative,  385.     See  also  Choroi- 
ditis, suppurative. 
Iridocleisis,  Holth's,  706 
Iridocychtis,  331,  348,  360.     See  also 
Cyclitis. 
after    extraction    of    cataract,     740 
serous,  360 
sjTnptoms,  348 
Iridodialysis,  345 
after  iridectomy,  697 
congenital,  324 
Iridodonesis,  449 
Iridoplegia,  62,  596 
reflex,  63 

unilateral,  64 
total,  62 
Iridotasis,  Borthen's,  706 
Iridotomy,  697 


804 


INDEX 


Iridotomy,  de  Wecker's  method,  697 
precorneal,  694 
simple,  698 
V-shaped,  698 
Ziegler's,  698 
Iris,  absence  of,  326 

pigment  in,  371 
anteversion  of,  346 
atrophy  of,  326,  330,  334 
bomb6,  329 

bridge  coloboma  of,  325 
change  in  color  of,  327 
cholesteatoma  of,  344 
coloboma  of,  325 
color  of,  52 
congenital  anomalies,  324 

aplasia  of  anterior  layers  of,   326 
cysticercus  in,  344 
cysts  of,  326,  344 
discoloration  of,  with  chronic  cyclitis, 

53 
diseases  of,  324 
displacement  of,  346 
disseminated  miliary  tubercle  of,  340 
endogenous  infection  of,  331 
exogenous  infection  of,  331 
forceps,  curved,  693 
foreign  bodies  in,  345 
gumma  of,  334,  356 
hyperemia  of,  326 
injuries  of,  345 
innervation  of,  57,  58 
irregularities  in  surface  of,  328 
melanoma  of,  344 
metastatic  carcinoma  of,  345 
mobility  of,  55 
multiple  cysts  of,  344 
muscular  tissue  of,  57 
nevi  of,  326 
operations  on,  692 
papilloma  of,  326 
parasitic  cyst  of,  344 
pearl-cyst  of,  344 
I)iebald,  53 

progressive  essential  atrophy  of,  330 
prolapse  of,  after  cataract  extraction, 

742 
pseudocoloboma  of,  325 
retention  cysts  of,  344 
retroflexion  of,  346 
sarcoma  of,  344 
scissors,  694 

section    of,     hemorrhage    after,    421 
serous  cysts  of,  344 
tulierclc  of,  340 

attenuated,  340 

confluent,  340 

disseminated  miliiiry,  340 
tumors  of,  344 
wounds  of,  345 
Iris-<"hamber  cysts,  344 
Iris-cysts  proper,  344 
Iris-svphilids,  334 
Iritis,'  32(),  506 
acute,  331 
after  cataract  extraction,  311,  710 


Iritis,  aqueous  humor  in,  328 
astigmatism  in,  328 
auto-toxemic,  327,  336 
cachectic,  327 
catamenaUs,  340 
causes,  326 

change  in  color  of  iris  in,  327 
chronic,  331,  334,  342 
complications,  329 
condylomatosa,  333 
contraction  of  pupil  in,  327 
course,  329 
diabetic,  327,  338 
diagnosis,  328 

disturbance  of  vision  in,  328 
eserin,  341 
fetal,  324 
fibrinous,  331,  332 
from      diseases      of  nasal     accessory 

sinuses,  647 
gonorrheal,  327,  339 

treatment,  339 
gouty,  327,  337 
gummatous,  334 
guttate,  337 
idiopathic,  340 
in  arthritis  deformans,  337 
infectious  disease,  341 
iridectomy  in,  342,  343 
irregularities    in    surface   of   iris   in, 

328 
lacrimation  in,  328 
luetic  fibrinous,  333 
malaise  in,  328 
metaboHc,  338 
nodular,  331 

operative  treatment  in,  342 
pain  in,  328 
papulosa,  333 
parenchymatous,  331 
pathology,  331 
pericorneal  injection  in,  327 
periodic,  340 
photophobia  in,  328 
plastic.  331,  332,  341 
posterior  synechia;  in,  327 
primary,  326 
prognosis,  329 
purulent,  331,  341.  385 
quiet,  337 
recurrent,  337 
relapses  of.  331 
rheumatic,  327,  336 
scrofulous,  327,  341 
secondary,  326.  342 

to    mucous    mcmliraiie    infottion, 
340 
septic,  327 

serous,  331.  342,  349.  360 
spongy,  332,  341 
sympathetic.  327,  312 
symptoms.  'A'27 
sypliililic.  327.  3.32 

pjin-iiciiN  iiiato\is,  XVA 

trcatiiiciil,  3.34 
tendfrucss  of  glolie  in,  32S 


INDEX 


805 


Iritis,  toxemic,  327,  336 

transient  myopia  in,  328 

traumatic,  306,  327,  341 

treatment,  331,  338 

true  syphilitic,  333 

tuberculous,  327,  340 
treatment,  341 

types  of,  331 

varieties,  327 

with  disorders  of  nutrition,  336 
Iritoectomv,  697,  698 
Iron,  172,  174,  178,  195,  219,  224,  225, 
241,  262,  314,  354,  478,  536.  552, 
559,  628,  635 

and  quinin,  628 
Irregular  astigmatism,  156 
Irrigation    of    anterior    chamber    after 

cataract  extraction,  731 
Irritation  miosis,  62 

mydriasis,  62 

of  retina,  461,  470 
Ischemia  of  retina,  461 
Itrol,  239 

Jackson  binocular  magnifying  lens.  52 
proptometer,  92 
test  for  malingering,  558 
for  muscle  balance,  76 

Jacob's  ulcer,  183 

Jaesche-Arlt    operation    for    trichiasis, 
667 

Javal's  controlled  reading  in  strabismus, 
606 

Javal-Schiotz     ophthalmometer,      116. 
763 
latest  model,  765 

Jaw-winking,  190 

Jenning's  self  recording  test  for  color- 
blindness, 70 

Jequiritol,  240,  241 
serum,  240 

Jequirity,  24  0 

Johnson's      method      of      determining 
astigmatism,  154 

Jones   (Wharton)   operation  for  ectro- 
pion. 672 

Juvenile  cataract,  428,  436 
glaucoma,  409 

Kalt's  corneal  suture,  738 

irrigations,  219 
Katophoria,  74 
Katotropia,  74 
Keratalgia,  traumatic,  305 
Keratectomy,  Ziegler's,  for  staphvloma, 

691 
Keratite  ulcereuse  en  sillons  etoiles,  269 
Keratitis,  259 

after  cataract  extraction,  742 

alphabet,  297 

anaphylactic,  292 

annularis  et  disciformis,  297 

bullosa,  286 

relapsing  traumatic,  305 

deep,  295 

dendritica,  269 


Keratitis  of  desiccation,  2S4 
diplobacillary,  205 
disciformis,  297 
lagophthalmo,  282,  284 
endogenous  gonorrheal,  221 
exanthematous,  267 
exposure,  190 
fascicular,  260 
filamentous,  300 

after  cataract  extraction,  742 

spontaneous,  300 

traumatic,  300 
flame-shaped  marginal,  243 
from     diseases    of    nasal    accessory 

sinuses,  647 
furrow,  269,  299 
gittrige,  298 
grill-like,  298 
herpetic,  285 
hypopyon,  266 

autoserotherapy  for,  274 

thermotherapy  in,  276 
inherited,  287 
interstitial,  287 

abscess  forms  of,  291 

anaphylaxis  in,  292 

and  punctata  keratitis,  291 

causes,  287 

central  annular,  291 

congenital,  288 

diagnosis,  291 

diffuse,  287 

epaulet-like  swelling  in,  289 

of  acquired  syphilis,  290 

pathology,  292 

prognosis,  291 

relapses  in,  292 

ring-like  opacities  in,  291 

stripe-like  opacities  in,  291 

symptoms,  288 

treatment,  293 
interstitialis    punctiformis    specifica, 

294 
leprous,  254 
maculosa,  295 
malarial,  269 
marginal  vascular,  291 
marginaUs  profunda,  297 

superficiahs,  268 
mycotic,  266 
neuroparalytic,  283 
non-ulcerative,  263 
nummular,  296 
oyster-shuckers',  304 
parenchymatous,  287 

circumscribed,  295 
petrificans,  300 
phlyctenular,  259 

causes,  259 

diagnosis,  261 

marginal,  260 

pathology,  261 

prognosis,  261 

symptoms,  260 

treatment,  261 
profunda,  173,  295,  352 


806 


INDEX 


Keratitis  punctata,  291,  294,  331,  340, 
342,  348,  349 
profunda,  294 
syphilitica,  294 
vera,  294 
purulent,  265 

pustuliformis  profunda,  297 
riband-like,  300 
scar,  280 

sclerotizing,  297,  314 
specific,  287 
striata,  307 
striated,    after    cataract    extraction, 

742 
subepithelialis  centralis,  295 
superficial  linear,  296 
superficialis  punctata,  295 
suppurative,  267 
syphilitic,  287 
traumatic,  303,  306 

striped,  307 
trophica,  300 
trypanosome,  294 
tuberculous,  270 
ulcerative,  263 
vascular,  287 
vesiculosa,  286 
xerotica,  284 
Keratocele,  281 
Keratoconjunctivitis,     259.     See     also 

Keratitis,  phlyctenular. 
Keratoconus,  302 
Keratoglobus,  426 
pellucidus,  426 
turbidus,  426 
Kerato-iritis  from  bee-sting,  304 
Keratomalacia,  246,  269,  282 
cause,  283 
S3Tnptoms,  283 
treatment,  283 
Keratome,  693 
Keratometer,  51 
Smith's,  51,  54 
Keratometry,  116,  763 
Keratomycosis  aspergillina,  266 
Keratoplasty,  282 
Keratoscope,  50 
Keratoscopy,  50 
Keratosis  senilis  pigmentosus,  179 

xerotic,  282 
Kerectasia,  280 
Key's   fat   implantation   into   Tenon's 

capsule,  715 
Klebs-LofTler  bacillus,  222,  223,  242 
Knapp   and   J.agraiiKc's   operation   for 

tumors  of  orbit,  719 
Kna[)[)'.s  knifc-iiccdle,  745 
lid  clamp,  660 

method  of  oxtracition  of  cataract,  738 
operation  for  after-cataract,  745 
for  cataract  without  iridectomy, 730 
for  i)t(!rygiuni,  ()83 
for  tniclioma,  (iSti 
Knife,  (;anahculus,  757 

cataract,  72K 
Knifc-noedle,  723 


ICnife-needle,  Knapp's,  745 
Koch's  old  tuberculin,  341 
Koch-Weeks  bacillus,  230 

conjunctivitis,  202 
Krauss'  enucleation  method,  710 
Kronlein's  resection  of  temporal  wall 
of  orbit,  720 
Gifford's  modification,  722 
indications,  722 
Kryptok  bifocal  lense.^,  163 
Kuhnt-Miiller  operation  for  ectropion, 

670 
Kuhnt's  method  of  conjunctivoplasty, 
683 
operation  for  trachoma,  689 
Kuhnt-Szymanowski  operation  for  ec- 
tropion, 670 
Kyanopsia,  560 

Lacrimal   abscess,  623.     See  Abscess, 

lacrimal. 
actinomycosis,  625 
apparatus,  diseases  of,  .620 

operations  on,  757 
blennorrhea,  of  infants,  624 
conjunctivitis,  243,  623 
disease,  prognosis,  626 
duct,  diseases  of,  treatment,  626 
glands,  atrophy  of,  620 

dacryoliths  of,  621 

dislocation  of,  traumatic,  621 

extirpation  of,  629,  760 

fistula  of,  621 

hypertrophy  of,  620 

Mikuhcz's  disease  of,  622 

mumps  of,  620 

palpebral  portion,  extirpation  of, 761 

spontaneous  prolapse  of,  620 

syphihs  of,  621 

traumatic  dislocation  of,  621 

tuberculosis  of,  621 

tumors  of,  621 
passages  examination  of,  277 
probes,  758 

introduction  of,  757 
reflex,  51 
region,   diseases  of,  from  diseases  of 

nasal  accessory  sinuses,  64S 
sac,  anomalies  of,  623 

chronic  distention  of,  623 

disea.ses  of,  causes,  624 
treatment,  ()26 

drainage  of,  7()l 

epithelioma  of,  026 

excision  of,  758 

extirpation  of,  620 

fistula  of.  t)2l,  (■>•_>(■) 

internal  fistula  of,  ()24 

mucocele  of,  623 

plasinoma  of,  tVJtJ 
sarcoma  of,  ()2() 

traclioiuH  of,  (525 

tuberculosis  of,  t)25 

tumors  of,  l»2() 
secretion,  cimracter  of,  under' pntiio- 
logic  conditions,  620 


INDEX 


807 


Lacrimal  stricture,  incision  of,  758 
syringe,  introduction  of,  758 
tumor,  623 
Lacrimation,  328 
Lacrimatory  gas,  effects  of,  245 
Lactate  of  calcium,  497,  739 

of  zinc,  536 
Lactic  acid,  256 

Lactophosphate  of  lime,  178,  277 
Lacunar  atrophy  of  optic  nerve,   399 
Lagophthalmos,  167,  191 
Lagrange's    combined   iridectomy    and 
sclerectomy,  700 
operation  in  glaucoma,  423 
Lagrange   and   Knapp's   operation  for 

tumors  of  orbit,  719 
Lambert's  method  of  removal  of  lens 

in  high  myopia,  724 
Lamina  cribrosa,  105 
Lancaster's   method    of   advancement, 

753 
Landolt's  method  of  advancement,  751 
ophthalmodynamometer,  80 
optotypes,  67 

treatment  for  strabismus,  603 
Lang's  operation  for  division  of  syne- 

chise,  699 
Lang-Frost  operation  of  implantation, 

714 
Lanolin,  183,  243 

Lantern    test    for    color-blindness,    70 
Lapis  divinus,  243 
Largin,  206 

argyrosis  from,  258 
Larvae,  tapeworm,  in  eye,  459 
Larval  conjunctivitis,  244 
Latent  deviation  of  ocular  muscles,  609 
Lateral  geniculate  body,  565 
Lattice-form    opacity    of    cornea,    298 
Laudanum,  174 

and  lead  water,  197 
Lead  amblyopia,  539,  552,  553 

incrustation  of  cornea,  301 
Lead-water,  170,  174,  196 

and  laudanum,  197 
Leber's  disease,  536,  564 
Lebrun's  method  of  cataract  extraction, 

726 
Lecithin,  541 
Leeching,  741 
Lens,  astigmatic,  155 

crystalline,  coloboma  of,  427 
congenital  anomahes  of,  427 
diseases  of,  427 
dislocation  of,  424,  448 
symptoms,  449 
treatment,  449 

under  Tenon's  capsule,  448  i 

foreign  bodies  in,  450  I 

removal  of,  aphakia  from,  447  ! 

in  high  myopia,  724 

removal  of,  in  myopia,  142 

star,  146 

testing,  protractor  for,  164 
Lenses,  23 
as  prisms,  22 


Lenses,  axes  of,  26 
biconcave,  30 
biconvex,  30 
bifocal,  163 
combination  of,  31 
concave,  23 

combination  with  convex,  32 

cyhndric,  31 

focus  of,  25 

focus  of,  conjugate,  25 

principal,  25 
image  of,  27 
concavoconvex,  30 
convex,  23 

combination  with  concave,  32 
cyhndric,  31 
focus  of,  23 
conjugate,  24 
virtual,  24 
principal,  23 
virtual  image  of,  27 
convexoconcave,  30 
cyhndric,  30 

combination  with  spheric,  32 
distortion  of  objects  by,  162 
examination  of,  by  transmitted  light, 

103 
focal  distance  of,  28 
formation  of  images  by,  25 
Frankhn  bifocal,  166 
horizontal  meridian  of,  32 
numeration  of,  28 
obHque  illumination  of,  51 
optical  center  of,  25 
planoconcave,  30 
planoconvex,  30 
Punktal,  31 
refractive  power  of,  28 
spheric,  30 

combination  with  cyhndric,  32 
split  bifocal,  166 
toric,  30 
trifocal,  166 
vertical  meridian  of,  32 
Lens-measure,  164 
Lenticonus,  427 
anterior,  427 
posterior,  427 
Lenticular  astigmatism,  146 

cataract,  428 
Lepra  bacillus,  266 
of  conjunctiva,  254 
of  eyehds,  187 
Lepros}^  nodules  of  cihary  body,   358 

of  cornea,  254 
Leprous  keratitis,  254 
Leptothricosis  conjunctivae,  241 
Leptothrix,  242 

Leroy  and  Dubois  ophthalmometer,  116 
Lethargic  encephahtis,  590 
Leukemic  retinitis,  480 
Leukoma,  adherent,  211,  278 
congenital,  307 
of  cornea,  278 
tattooing  cornea  in,  691 
Leukosarcoma  of  choroid,  387,       388 


808 


INDEX 


Lid  abscess,  197 
Lid-border,  artificial,  667 

eczema  of,  175 

hyperemia  of,  175 

seborrhea  of,  175 
Lid-olo.sure  refiex  of  i)ui)ils,  57 

retinal,  51 
Lid-edema,  1.S9 
Lid-elevator,  72.S 

Lids,  granular,  229.     See  also  Trachoma. 
Liebreich's  method  of  cataract  extrac- 
tion, 726 
Ligamentum  pectinatuni.  345 
Light.  17 

difference,  418 

injurious  effect  of,  560 

minimum,  6cS,  41S 

perception,  88 
quahtative,  67 

rays  of,  17,  21 

red-free    ophthalmoscopy    with,    111 

reflex,  105 

spot,  104 

transmission  of,  17 
Light-adaptation,  68 
Light-difference,  68 
Light-minimum,  68,  418 
Light-reflex,  105 

of  pupil,  conccnsual,  5(),  60 
direct,  55,  59,  60 
indirect,  56,  60 
Light-sense,  67,  187 

in  atrophy  of  optic  nerve,  531 

in  glaucoma,  418 

in  myopia,  137 

test  for,   in  periphery  of  retina,   88 

testing  for,  68 

test-types  for,  68 
Lightning-stroke  cataract,  435 
Limbus,  fibroma  of,  225 
Limit  of  perception,  35 
Lindner's  initial  bodies,  231 
Line  of  fixation,  41 

visual,  41 
Linear  cauterization  of  fornix,  225 

extraction  of  cataract,  724 
LifXTuiu  rctirialis,  479 
Li|)oiiia  of  CNchds,   ISI 
Li])pituilo,  176 

ulcerosa,  175 
Li(juor  potassa,  239 

Lister's  substitute  for  evisceration,  713 
Lithiasis  conjunct iva%  244 
Lloyd's  stereocami)imeter,  90 
Location    of    opacities    in    transparent 

media,  103 
Locomotor  ataxia,  534 

opiic  nerve  typ((,  534 

pulse  of  rcliii.-d  arteries,  10() 
I^iofllcr        bacillus.     See        Klcbs-LiJJJlvr 

haviUuH. 
J..OOP,  wire,  728 

Loring's  oi)hlhaImoscopc,  95,  96 
I..O.SS  of  vision,  545 
Lotio  nigra,  172 
Loupe,  corneal,  52 


Lugol's  solution,  272 

Lumbar  puncture  in  optic  neuritis,  527 

Lunar  caustic,  272 

Lupus  of  conjunctiva,  254 

of  cornea,  299 

of  orbit,  639 

vulgaris  of  eyelids,  183,  187 
Lymphangiectasis  of   conjunctiva,   250 
Lymphangiomas  of  eyelids,  ISO 
Lymphoma  of  conjunctiva,  241 

of  eyehds,  183 
Lympliorrhagia  of  fundus,  509 
Lymph-space  theory-  of  optic  neuritis, 

529 

Macropsi.\,  62,  373,  465,  560 
Macula,    black    spot    of,    in    mvopia, 
139 
holes  in,  508,  509 
lutea,  41,  108 

appearance  of,  109 
black  spot  of,  109 
color  of,  110 
halo  of.  109 

sj'mmetric  changes  in  infancy,  513 
traumatic  perforations  of,  508 
vessels  of,  109 
whitish  ring  of,  109 
of  cornea,  278 
Macular  coloboma,  370,  383 
fan,  522 
fasciculus,  565 
hemianopsia,  568 
reflex,  109 

region,  progre.ssive  family  degenera- 
tion in  ,  514 
Maculocerebral  degeneration,  514 
McMullen's    operation    for    trachoma, 

687 
McRej'nolds'  operation  for  i)tcrvgium, 

683 
Madarosis,  176 
Maddox  multiple  rod,  79 
obtuse-angled  prism,  78 
rod  test,  76,  77 

for  horizontal  derivation,  79,  SO 
for  ocular  muscles,  79 
for  vertical  deviation,  79,  80 
rod-screen  test,  SO 
Magiu'sium  sulphate,  2S1 
Magnet,  giant,  321 
liuabs,  321 
Inneiipol,  321 
sling,  321 
Malai.se.  32S 
Malarial  ainblvopia,  552 

keratitis.  2()9 
Male  fern  amblyopia,  553 
Malignant  edema  of  eyelid,  170 
eneautiiis,  25S 
pustule  of  eyelid,  170 
Malingering  and)lyopia.  557 
liinucular  test  for,  5.58 
dipli>|)ia  lest  for,  557 
Harlan's  test  for,  557 
Snellen's  test  for,  557 


INDEX 


809 


Marginal  ^degeneration  of  cornea,  299 

ectasia,  299 

eczema,  175 

keratitis  phlyctenular,  260 

ulcer  of  cornea,  infected,  bacillus  of, 
267 

vascular  keratitis,  291 
Mariotte's  blindspot,  89 
Marple's  ophthalmoscope,  96,  97 
Mask,  Ring's  ocular,  733 
Massage     in     obstruction     of     central 
artery  of  retina,  505 

of  cornea,  281 

of  eyeball  in  chronic  glaucoma,  419 
Massive  retinal  exudation,  499,  500 
Maxwell's    operation    to    enlarge    con- 
tracted socket,  681 
Mechanical  conjunctivitis,  201 

theory  of  optic  neuritis,  529 
Mechanism  of  accommodation,  35 
Media,  transparent,  location  of  opaci- 
ties in,  103 
Median  tarsorrhaphy,  284 
Megalocornea,  426 
Megalophthalmos,  630^ 
Meibomian   cyst,     182.      See     also 
Chalazion. 

gland-duct,  wart  on,  180 

glands,  retention  cysts  of,  183 
Melanocarcinoma  of  conjunctiva,  253 
Melanoma  of  choroid,  390 

of  conjunctiva,  253 

of  iris,  344 
Melanosarcoma  of  choroid,  388 
Melanosis  of  conjunctiva,  251 

sclerse,  322 
Meller's  method  of  excision  of  lacrimal 

sac,  760 
Membrane-forming  conjunctivitis,  223 
Membranous  conjunctivitis,  210,  221 
Meningitis,  tuberculous,  393 
Meningococcus  conjunctivitis,  201 

intracellularis,  452 
Mercuric  chlorid,  200.  335 
Mercurochrome,  221,  271,  627,  628 
Mercurophen,  207,  238,  271,  272,  627 

628  712        * 

Mercury,  178,  179,  190,  195,  224,  256, 

278,  293,  315,  322,  335,  338,  339, 

342,  357,  366,   367,   368,  380,  466, 

471,  473,  526,  535,  539,    632,    741 

amblyopia,  553 

and  belladonna,  338 

cyanid.     See  Cyanid. 

oxid.     See  Oxid. 

with  chalk,  293 
Meridians,  horizontal,  32 

of  eye,  146 
principal,  146 

vertical,  32,  573 
Metabohc  iritis,  338 
Metal  spoon,  728 

MetalUc  foreign  bodies,  removal  of,  716 
Metamorphopsia,  373,  465,  491 
Metastatic  carcinoma  of  ciliary  body, 
358 


Metastatic  carcinoma  of  iris,  345 
dacryo-adenitis,  620 

gonorrheal  conjunctivitis,  220 

ophthalmitis,  386,  472 

optic  neuritis,  525 

retinitis,  471 
Meter  angle,  20,  45 

centrads  and,  relation  of,  20 
of  convergence,  44 

prism-diopters  and  relation  of,  20 
Methyl-alcohol  amblyopia,  553,  554 

blindness,  554 
Methylatropin,  125 
Microblepharon,  177 
Micrococcus  catarrhalis  conjunctivitis, 

201 
Microphakia,  427 
Microphthalmos,  309,  546,  630 
Micropsia,  61,  373,  465,  560 
Microscope,  corneal,  52 
Migratory  ophthalmia,  359 

ophthalmitis,  364 

pustule,  260 
Migraine  from  astigmatism,  150 

hemianopsia  of,  561 

ophthalmic,  in  glaucoma,  417 

ophthalmique,  561 

ophthalmoplegic,  590 
Mikuhcz's  disease  of  lacrimal  gland,  622 
Miliary  aneurysms   with  retinitis,   501 

choroidoretinitis,  372 
Mihtary  conjunctivitis,  243 

ophthalmia,  229 
Milium,  195 
Milk,  whole  boiled,  in  eye  infections, 

277 
Mineral  waters,  278 
Miners'  nystagmus,  617 
Minimum  stimulus,  68 
Miosis,  62,  327 

irritation,  62 

paralytic,  62,  63 

spastic,  63 

spinal,  63 

traumatic,  62 
Miotic  nerves,  58 

tract,  59 
Mires  of  ophthalmometer,  764 
Mirror,  catoptric  power  of,  187 

concave,  93,  123 
skiascopy  with,  118 

convex,  94 

plane,  93 

skiascopy  with,  117 
Mixed  trachoma,  234 
Mobihty  of  eyes,  73 

of  iris,  55 
Moebius  sign,  642 
Moles  of  conjunctiva,  251 
Molluscum  contagiosum,  195 

corpuscles,  196 

fibrosum  of  eyelids,  181 

sebaceum,  195 
Monochromatic  vision,  70 
Monocular  diplopia,  618 
in  cataract,  430 


810 


INDEX 


Mooren's  ulcer,  zinc  ions  in,  277 
Morax  method  of  blepharoplasty,  679 
Morax-Axenfeld  bacillus,  177,  230 
conjunctivitis,  204 

diplobacillus,  266 
Morgagnian  cataract,  433 
Morning  ptosis,  243 
Morphin,  174,  189,  219,  278,  338,  387, 

419,  658,  739,  744 
Mosher's  operation,  761 
Motais'  operation  for  ptosis,  665 
Movements    of    eyeballs,     and     their 

anomalies,  572 
Mucocele  of  ethmoid  sinus,  645 

of  frontal  sinus,  643 

of  lacrimal  sac,  623 
Mucous  membrane,  transplantation  of, 

in  sj-mblepharon,  684 
Mules'  operation,  713 

Dimitry's  modification,  713 
for  ptosis,  661 
Ray's  modification,  713 
Mtiller-Kuhnt  operation  for  ectropion, 

670 
Miiller's  operation  for  retinal  detach- 
ment, 708 
Mumps  of  lacrimal  gland,  620 
MuscsD  voUtantes,  454 
Muscle-resection     operation,     Reese's, 

754 
Muscles,  pupil,  55 
Mustard  gas  conjunctivitis,  246 

efTects  of,  245 
Muscular  asthenopia,  612 
Mycotic  keratitis,  266 
Mydriasis,  alternating,  65 

drug,  62 

irritation,  62 

medicinal,  62 

one-sided,  65 

paralytic,  62 

spastic,  62 

springing,  65 

traumatic,  346 
Mydriatic  glaucoma,  413 

nerves,  58 

tract,  59 
Mydriatics,   dilatation  of  pupil  from, 
61,  62 

use  of,  123 
Mydrol,  125 
Myodesopia,  454 
Myoma  of  ciliary  body,  358 

of  orbicularis,  181 
Myopia,  22,  133 

angle  gamma  in,  136,  138,  139 

astigmatism  in,  137,  140 

axial,  134 

black  spot  of  macula  in,  139 

causes,  134,  136 

ciliary  body,  140 

conus  in,  137 

correction,  140 

curvature,  134 

(iofiriition,  133 

degree  of,  141 


Myopia,  determination,  140 

divergence  strabismus  in,  137 

enlongation  of  eyeball  in,  135 

far  point  in,  133 

from  corneal  opacities,  134 

from  scleroticochoroiditis,  135 

full  correction  in,  143 

green  spot  in,  139 

heredity  in,  135 

high,  removal  of  lens  in,  724 
with  glaucoma,  425 

in  diabetes,  135 

index,  135 

late  development  of,  135 

lengthening  of  eye  from,  113 

light-sense  in,  137 

mahgnant,  137,  138 

operation  for,  142 

ophthalmoscopic  appearances  in,  140 

ordering  of  glasses  in,  143 

pernicious,  137,  138 

phakolysis  in,  142 

position  of  lens  for,  144 

posterior  staphyloma  and,  139    • 

prevalence  of,  134 

prodromal,  429 

progressive,  137,  139 

prophylactic  measures  in,  141 

removal  of  lens  in,  142 

school,  134 

hygiene  and,  142 

scrotoma  in,  139 

shortening  of  eye  from,  113 

skiascopy  in,  119 

stationary,  137 

strength  of  eyes  in,  138 

symptoms,  137 

tenotomy  of  external  rectus  in,  142 

transient,  328 

treatment,  141 

varieties,  134 

visual  acuteness  in,  144 

with  esophoria,  145 
Myopic  choroiditis,  384 

crescent,  137 
Myopin,  atropin  in,  142 
Myosarcoma  of  ciliary  body,  358 
Myotonic  pupil  movement,  65 

NiEvus    pigmentosus    of    conjunctiva, 

251 
Naphthalin  cataract,  435 
Nasal    accessory   sinuses,  ""diseases^  of, 
ocular  complications  in,  647 
arteries,  105 
catarrh,  201,  205 
duct,  anomalies  of,  623 
diseases  of,  causes,  624 
ol)st ruction  of,  624 
treat  merit,  620 

window   resection   of,    in    stenosis, 
701 
step,  H6nne's  103,  404 
NiLsonharynx,  diseiu^es  of,  625 
Nagel's  anomaloscope,  72 

card    test    for    color    blindness, ^71 


INDEX 


811 


Near  point  of  eye,  37,  38 
in  presbyopia,  158 
of  accommodation,  38 
of  convergence,  46 
test  for,  76 
Near-sightedness,  127.    See  also  Myopia. 
Nebula  of  cornea,  278 
Necrosis  cornese,  282 

of  orbit,  632 
Necrotic  conjunctivitis,  infectious,  208 
Needle,  Bowman's  stop,  723 

knife-,  723 
Knapp's,  745 

lance-headed,  723 

operation  for  cataract,  722 
after-treatment,  724 
instruments  required,  722 

paracentesis,  690 

tattooing,  692 
Negative  aberration,  122 
Neglected  eyes,  598 
Neisser  bacterin,  339 

gonococcus  of,  209 
Neoarsphenamin,  335 
Neosalvarsan,  179,  294,  335,  354,  357, 

368,  380,  526,  536,  741 
Nephritis,  chronic,  497 

interstitial,  474 

parenchymatous,  474 

retinitis  in,  473 

scarlatinal,  474 

trench,  476 
Nerve,  optic.     See  Optic  nerve. 
Nerve-fibex  layer  of  retina,  564 
Nerve-head.     See  Optic  nerve,  head  of. 
Nerves,  miotic,  58 

mydriatic,  58 
Nervous  asthenopia,  462 

diseases,  dilatation  of  pupil  in,  62 
Neuralgia,  409,  462 

supra-orbital,  269 
Neurasthenic  asthenopia,  462 
Neurectomy  for  sympathetic  ophthal- 
mitis, 367 

opticociliary,  716 
Neuritis,  alcohol,  64 

axial,  537.     See  also  Optic    neuritis. 

descending,  528 

glaucoma  and,  415 

multiple,  63 

optic,     473,     518.     See     also     Optic 
neuritis. 

retrobulbar,  536,  537.     See  also  Optic 
neuritis,  orbital. 
Neuro-epithelioma  of  retina,  510 
Neuro-epitheUum      layer     of     retina, 

564 
Neurofibromatosis  of  eyelids,  181 
Neuroma  of  ciliary  nerve,  358 

of  eyehds,  181 
Neuroparalytic  keratitis,  283 
Neuroretinitis,  474,  519 

from     disease     of     nasal     accessory 
sinuses,  647 
Neurosis,  reflex,  613 

traumatic,  561 


Neurotomy,   opticociliary,   in  absolute 

glaucoma,  423 
Neurotonic  convergence  reaction,  65 
Nevi  of  eyelids,  180 
of  iris,  326 
of  orbit,  639 
Nevus  pigmentosus,  180 
Nicotin,  ophthalmoplegia  from,  593 
Night-blindness,  247,  485,  558 
family,  559 
functional,  558 

in  retinitis  pigmentosa,  485,  489 
Nitrate  of  silver,  177,  200,  206,  207,  213, 
214,  215,  219,  221,  222,  227   238, 
242,  250,  270,  272,  536,  628,  639, 
686,  687,  706 
amblyopia  from,  553 
argyrosis  from,  258 
Nitric  acid,  180,  272 
Nitrite  of  amyl,  461,  505,  541,  554 
Nitrobenzol,  amblyopia  from,  539,  553 

poisoning  from,  556 
Nitroglycerin,  420,  422,  425,  497,  536 

in  optic  nerve  atrophy,  536 
Nitrophenol  amblyopia,  553 
Nitrous  oxid,  655 
Nocturnal  amblyopes,  558 
Nodal  point,  34 
Nodes,  episcleral,  311 
Nodular  opacities  of  cornea,  298 

scleritis,  312 
Noduli  cornese,  295 
Noma  of  eyelids,  170 
Non-accommodative     convergence  ex- 
cess, 609 
Non-crossed  fasciculus,  565 
Non-specific     purulent     conjunctivitis, 

221 
Normal  acuteness  of  vision,  35 
Nosophen,  262,  276 
Novocain,  695,  658,  748 
Nuclear  cataract,  432 

layer  of  retina,  external,  564 
palsy,  acute,  593 
chronic,  593 
Numbering  of  prisms,  19 
Numeration  of  lenses,  28 
Nummular  keratitis,  296 
Nux  vomica,  541,  613 
Nyctalopia,  558,  559 
acute  essential,  558 
chronic,  558 
retinitis,  559 
Nystagmus,  616 
acquired,  617 
congenital,  617 
hereditary,  617 
in  retinitis  pigmentosa,  485 
latent,  618 
miners',  617 
resilient,  617 
rythmic  form,  617 
treatment,  618 
true,  618 

undulatory  form,  617 
vestibular,  618 


812 


INDEX 


Nystagmus,  vibratory.  (ilT 
voluntary',  618 

Oblique  illumination,  51 

for  detection  of  cataract,  431 
inferior,      573.     See     also      Inferior 

oblique. 
muscles,     insufficiency    of,     78,     79. 

See  also  Cyclophoria. 
superior,     572.     See     also    .Superior 
oblique. 
Ob.scuration  of  one-half  of  visual  field, 

564 
Obscurity  of  sight,  545 
Obsole.scent  tubercles  of  choroid,  394 
Obstetric  injuries  of  cornea,  307 
Obstruction  of  canaliculus,  622 

of  nasal  duct,  624 
Obtuse-angled    prism    of    Maddox,    78 

test  of  ocular  muscles,  78 
Occipital  lobe,  566 
Occlusion    treatment    in    concomitant 

squint,  603 
O'Connor's    method    of    advancement, 

753 
Ocular    complications    of    diseases    of 
nasal    accessory    sinuses,    647 
gyration,  paralyses  of,  594 
mask,  Ring's, 

motility,  disturbances  of,  640 
muscles,  anatomy  of.  572 
associated  paralysis  of,  594 
balance  of,  73 

abnormal,  609.     Sec  also  Hetero- 
phoria. 
classification,  587 
cobalt  test  for,  79 
cover  test  for,  74 
crossed  lateral  deviation  of,  75 
deviations  of,  73,  75 
horizontal,  79 
vertical,  79 
eciuiiibriurii  test  for,  75 
e.xterior,    paralysis    of,    580,    591. 
See    also    Strabismus,    paralytic. 
external,  balance  of,  73 
homonymous  lateral  deviation  of. 

75 
horizontal  deviation  of,  79 
iiisuflicic'iicy      of,      73.     See      also 

ll('tcr<)i)lioria. 
interior,  paraysis  of,  595 
.Jackson's  test  for,  7() 
latent  deviation  of,  73,  609 
lateral    deviation    of,    cro.s.sed,    75 

hoinonvmous,  75 
Maddox  rod  test  for,  76,  77,  79 

rod-screen  ti'st  for,  SO 
Miaiiifcst  dcviiition,  73 
ol)li(|ue,     iiisiifnciency    of,    7S,    79. 

Sec  idso  ('ncld/ilionii. 
oblusc-atiglcd    prism    li-sl    for,    78 
opera!  io!is  on,  747 
parallax  test  for,  74 
|)aralvsis  of,  causes,  5S8 
cerebral,  590 


Ocular  muscles,  paralysis  of,  conjugate 
lateral,  594 
Duane's  diagnostic  table,  588 
from  injuries,  590 
from  reflex  disturbances,  590 
from  spinal  anesthesia,  590 
mechanical  treatment,  592 
prognosis  of,  592 
relative  frequency  of,  592 
syphihs  in,  589 
table  of  diplopia  in,  588 
tenotomy  in,  .591,  593 
treatment,  592 
phy.siologic  action  of,  572 
prism  tests  for,  75 
rod  test  for,  79 
rod-screen  test  for,  80 
screen  test  for,  74 
vertical  deviation  of,  79 
von  Graefe's  test  for.  75 
Oculomotor  nerve,  57,  572 
paralysis,  586 
recurrent,  590 
Oculo-orbital   fascia,   inflammation   of, 

635 
Oidium,  171 
Oil  of  cade,  172 
of  turpentine,  368 

of  wintergreen,  amblyopia  from,  553 
Ointment,  White's,  732 
Olive  oil,  257 

One-piece  bifocal  lenses,  163 
One-sided  mydriasis,  65 
Opacities,  corneal,  298 

after  cataract  extraction,  742 
congenital,  309 
grill-like,  298 
guttate,  298 
myopia  from,  134 
nodular,  298 
striate  clearing  of,  282 
in  cataract,  432 
in  retinitis  ])igmentosa,  4S4 
in  transparent  media.  103 
in     vitreous,     452,     4()().     See     also 

Vitreous  opaciitiis. 
inflammatory,  453 
sno\v-i)all,  453 
Open  method  of  managing  eyes  after 

cataract  extraction,  73,3 
Operations,  t')54 

preparation  for,  654 
( »l)litlialiiiia,    201.     See    al.so    Cotijutic- 
livilis. 
chronic,    242 

l']gyj)tian,    229.     See    also    Conjunc- 
tivitis, follirulur. 
electric,  5.")9 
follicul.'ir,  22S 
gonorrheal,  208 
liepalica,  379 
migratory,  3.59 

military,     229.     See     .also     Conjunc- 
tivitis, folliculnr. 
neonatorum,     208.     See     jilso     Con- 
junctivitis neonatorum. 


INDEX 


813 


Ophthalmia  nodosa,  246 
phlyctenular,  224 
purulent,  217 
pustular,  225 
scrofulous,  224 

sympathetic.     See  Ophthalmitis,  sym- 
pathetic. 
tarsi,  175 
Ophthalmic  artery,  aneurysm  of,  641 
migraine  in  glaucoma,  417 
nerve,  59 
soaps,  177 

vein,  obstruction  of,  641 
Ophthalmitis,  173,  451 
endogenous,  472 
metastatic,  386,  472 
migratory,  364 

sympathetic,  alopecia  with,  366 
anaphylactic  reaction  in,  366 
blood-serum  in,  368 
causes,  359 

ciUary  nerve  theory,  364 
Critchett's  operation,  368 
endogenous  theory,  365 
enucleation  in,  366,  367 
formation   of   fixation   abscess  in, 

368 
frequency,  362 
incubation  period,  362 
infection  theory,  364 
iridectomy  in,  367 
manifestations  of,  360 
metastasis  theorj',  365 
neurectomy  for,  367  j  , 
pathogenesis,  364 
pathologic  anatomy,  363 
premonitory  symptoms,  361 
prognosis,  369 
prophylaxis  in,  366 
sjTnptoms,  361 

theory  of  anaphylactic  uveitis,  365 
treatment,  366,  367 
varieties  of,  360 
whitening  of  eyebrows  in,  366 
Ophthalmoblennorrhea  of  young  girls, 

217 
Ophthalmodiaphanoscope,  115 
Ophthalmodiaphanoscopy,  115,  391 
Ophthalmodynamometer,  80 
Ophthalmomalacia,     396.     See     also 

Phthisis  bulbi. 
Ophthalmometer,  116 
Chambers-Inskeep,  116 
Hardv,  116 

Javal-Schiotz,  116,  763,  765 
Leroy  and  Dubois,  116 
Reid,  116 
Sutcliffe,  116 
use  of,  763 
Ophthalmometry,  116,  763 
Ophthalmoplegia,  693 
acute,  593 
chronic,  593 
congenital,  594 
exterior,  593,  630 
hereditary,  594 


Ophthalmoplegia,  interior,  593 
migraine  of,  590 
progressive,  593 
stationarj',  593 
total,  593 

transient  bilateral,  593 
treatment,  594 
Ophthalmoplegic  migraine,  590 
Ophthalmoneuromyelitis,  525 
Ophthalmoscope,     93,     95.     See     also 
Ophthalmoscopy. 

correction  of  hyperopia  with,  132 
Crampton's,  96 
demonstrating,  96 

determination  of  astigmatism  by,  113 
of  compound  astigmatism  by,  114 
of  refraction  bv.  111,  115 
electric,  96,  101  ' 
GuUstrand,  96 
Loring,  95,  96 
Marple,  96,  97 

methods  of  using,  92,  99,  101 
refraction,  95 
von  Helmholtz,  95 
Ophthalmoscopic  changes  in  exophthal- 
m9s,  642 
test  in  cataract,  430 
Ophthalmoscopy,  93,  101 
direct  method,  97,  101 
image  in,  98 
position  of  patient,  101 
size  of  image  in,  99 
formation  of  inverted  image  in,  100 
indirect  method,  99,  114 
image  in,  99 
size  of  image  in,  100 
with  red-free  light,  111 
Opiates,  174 
Opium,  219,  258,  278,  335,  387 

amblyopia,  539 
Opsonic  index,  172 
Optic  axis,  41 

centers,  determination  of,  164 
of  lens,  25 
primary,  564 
chiasm,  564 
disk,  congestion  of,  517 
irregularities  in,  516 
shreds  of  tissue  on,  517 
nerve,  104 

anemia  of,  518 
anomaUes  of,  106 
congenital,  516 
avulsion  of,  541 
atrophy  of,  361,  399,  530 
adaptation  in,  532 
alteration  in  center  of  disk  in,  531 
causes,  533 
central  vision  in,  531 
choroiditic,  530,  533 
color  changes  in,  530 
consecutive,  530,  533 
course,  535 
diagnosis,  535 
embolic,  534 
eye-ground  changes  in,  531 


814 


INDEX 


Optic  nerve,  atrophy  of,  field  of  vision 
in,  532 

gray,  530,  533 

gray-red,  531 

hereditary,  536 

hght-sense  in,  531 

margins  of  disk  in,  531 

nerve-head  in,  530 

neuritic,  530 

pathologic  anatomy,  534 

postpapillitic,  530,  533 

primary,  530,  533,  534 

prognosis,  535 

progressive,  533 
with  scotoma,   564 

pupil  in,  532 

retinal,  530,  533 

scleral  ring  in,  531 

secondary,  530,  533,  534 

spinal,  533 

stationary,  with  scotomas,  563 

symptoms,  530 

tabetic,  533 

thrombotic,  534 

treatment,  535 

varieties  of,  533 

vessel  changes  in,  531 

Wassermann  test  in,  535 

with  excavation,  408 
cavernous  atrophy  of,  399 
coloboma  of  sheath,  516 
congenital  anomalies  of,  516 
fibers  of,  congenital  pigmentation 

of,  516 
diseases  of,  516 

from  diseases  of  nasal  accessory 
sinuses,  647 
drusen  in,  543 
edema  of,  intra-ocular,  518 
engorgement-edema  of,  518 
fibers  of,  meduUated,  516 

opaque,  516 

pigmentation  of,  516 
grayness  of,  530 
head  of,  anemia  of,  518 

color  of,  517 

cong(!stioii  of,  517 

cupping,  in  glaucoma,  398 

hyperemia  of,  517 
hyaline  bodies  in,  543 
hy|)ercinia  of,  331 
inflammation    of,    518.     See    also 

O/dic  neuritis. 
injury,  541 

iiifltunmation  of,  intra-ocular,  518 
intradural  tumor  of,  541 
lacunar  atrophy  of,  399 
medullat(Ml  fibers  of,  516 
neuritis,  symptoms,  519 
()l)ai|U(!  fibers  of,  516 
shi-alli  of,  hcruatoma  of,  549 

licMiorrhago  into,  519 
tumor  of,  542 

Hymptouis,  542 

treatment,  543 
typo  of  tabes  dorsalis,  534 


Optic  neuritis,  331,  473 
acute  blindness  in,  524 
arteries  in,  520 
causes,  523 

cerebral  decompression  in,  527 
changes  in  nerve-head  in,  519 

in  vessels,  520 
course,  521 

descending,  519,  524,  528 
diagnosis,  521 
edema  of  retina  in,  522 
external  appearances  in,  521 
field  of  vision  in,  520 
from  brain  disease,  524 
from   diseases   of   nasal   accessory 
sinuses,  526 

of  orbital  region,  526 
from  general  diseases,  525 
from  meningitis,  524 
from  skull  deformities,  525 
from  toxic  agents,  525 
from  tumor  of  brain,  523 
hemianopsia  in,  521 
hemorrhages  in,  520 
hereditary,  536 
infectious,  525 
inflammatory.  530 

theory  of,  529 
interstitial,  530 
intra-ocular,  518 
light-sense  in,  520 
lumbar  puncture  in,  527 
lymph-space  theory  of,  529 
macular  fan  in,  526 
mechanical  theory  of,  529 
metastatic,  525 
nerve-head  in,  520 
orbital,  acute,  537 

cause,  537 

course,  538 

prognosis,  53S 

.symptoms,  537 

treatment,  539 
chronic,  537,  539 

causes,  539 

course,  541 

prognosis,  541 

symptoms,  539 

treatment,  541 
idiopathic,  538 
symptoMKitic,  .538 
papillitic  atrophy  in,  .522 
pathogenesis.  52S,  529 
patiiologic  anatomy,  530 
peripheral,  51S 
prognosis,  523 
puncture   of    corpus    callosum    in, 

527 
significance  of,  528 
st.'igcs  of,  522 
tower  skull  and,  .525 
toxin  tlieory  of,  529 
treatment,  526 
veins  in,  520 
vision  in,  52t) 
with  scotoma,  564 


INDEX 


815 


Optic  radiations,  566 
Optical  iridectomy,  444,  694 
Opticociliary    neurotomj-    in    absolute 

glaucoma,  423 
vessels,    108 
Optochin,  276,  711 

amaurosis,  554 
Optometer,  116 
Optometry,  116 
Optotj'pes,  Landolt's,  67 
Orbicularis,  mj-oma  of,  181 
paralysis  of,  190 
tonic  cramp  of,  189 
Orbit,  abscess  of,  645 

from   diseases   of  nasal   accessory 
sinus,  649 
angiomas  of,  637 
anomalies  of,  630 
caries  of,  632 
cellulitis  of,  633 

after  tenotomy,  749 

causes,  634 

from   diseases   of  nasal   accessory 
sinuses,  649 

prognosis,  634 

progress,  634 

treatment,  635 
cephaloceles  of,  638 
cysts  of,  636 

removal,  719 

true,  638 
diseases  of,  630 

frontal  headache  in,  631 

pain  in,  630 

synaptoms,  630 

vision  in,  631 
encephalocele  of,  639 
endotheUoma  of,  638 
epithehoma  of,  639 
exenteration  of,  719 
exostoses  of,  639 

operation  for,  720 
fistula  of,  631,  645,  648 
gas  bacillus  infection  of,  650 
hemorrhage  into,  650 
injuries  of,  649 

treatment,  650 
lupus  of,  639 
necrosis  of,  632 
nevi  of,  639 
osteoma  of,  639 

operation  for,  720 
periostitis  of,  631 

causes,  631 

prognosis,  632 

sjTnptoms,  631 

treatment,  632 
phlebitis  of  veins  of,  634 
phlegmon  of,  633 
polypi  of,  639 
sarcoma  of,  637,  638,  639 
temporal     wall,     resection     of,     720 
true  cysts  of,  638 
tumors  of,  636 

nature  of,  636 

originating    in     bony     wall,     639 


Orbit,  tumors  of,  originating  in  cavi- 
ties, 639 
in  tissues,  637,  639 
in  vascular  disease  in  cavity,  640 
prognosis,  637 
removal,  719 

Lagrange  and  Knapp's  method, 
720 
symptoms,  636 
treatment,  637,  641 
wound  of,  treatment,  650 
Orbital  optic  neuritis,    537.     See  also 
Optic  neuritis,  orbital. 
palsies,  589 

sockets,  cicatricial,  Esser's  epithelial 
inlay  for,  680 
Maxwell's  operation  to  enlarge, 

681 
operations     for     prosthesis     in, 

679 
Schwenk  and  Posey's  operation 

to  enlarge,  681 
Wiener's   operation   to   enlarge, 
681 
Orbitopalpebral  cyst,  630 
Orthoform,  239 
Orthophoria,  74,  610 
Orthoptic     exercises    in    heterophoria, 
616 
training  in  strabismus,  603 
treatment  of  concomitant  squint,  603 
Oscillating  field,  463 
Osmic  acid  amblyopia,  553 
Ossification  of  choroid,  396 
of  ciharj^  body,  358 
of  tarsus,  182 
Osteoma  of  frontal  sinus,  643   • 
of  orbit,  639 

operation  for,  720 
of  sphenoid  sinus,  646 
Outward  torsion,  572 
Overcoming  prisms,  575 
Oversightedness,  127.     See  also  Hyper- 
opia. 
Oxid  of  mercury,  172,  177,  183 

of  zinc,  172 
Oxycyanid  of  mercury,  207,  219 
Oyster-shuckers'  keratitis,  304    . 
Ozena  baciUus,  266 

Pachymeningitis,  524 
Paderstein's  inclusion  bodies,  204 
Pagenstecher's    salve,    177.     See    also 
Yellow  oxid  of  mercury. 

cataract  extraction  without  capsul- 
otomy,  726 

subcutaneous   thread    operation   for 
ptosis,  661 
Pain    after    cataract    extraction,    738 

ciUary,    328 

in  cataract,  429 

in  glaucoma,  401 

in  orbital  disease,  630 

in  retinitis,  465 

reaction  of  pupil,  57 
Pallid  edema  of  the  disk,  552 


SIG 


INDEX 


Palpebral  chromickosi.s,  I'JO 

portion  of  lacrimal  gland,  extirpation 

of,  761 
reflex,  ol 

of  pupils,  51,  57,  65 
Panas'  fluid,  200 

operation  for  ptosis,  601 
Pannus,  230 
crassus,  236 
peri  torn  y  in,  241 
phlyctenular,  261 
tennis,  236 
with  trachoma,  236 
treatment,  240 
Panophthalmitis,  211,  246,  386 
bacilli,  387 
emboHc.  472 
from  choroiditis,  385 
Papilla.     See  Optic  nerve. 
Papillary  trachoma,  233 
Papilledema,  519,  528 
Papillitis,    518,    525,    519.     See    also 

Optic  neuritis. 
Papilloma  of  eyelids,  179,  181 

of  iris,  326 
Papillomacular  bundle,  565 
Papilloretinitis,  360,  473 

sympathetic,  360 
Paracentesis  cornese,  689 
in  uveitis,  355 
needle,  690 
of  cornea,  272 
Paracentral  scotomas,  563 
Paradoxic  convergence  reaction,  66 
pupil  dilatation,  66 
pupillary  reactions,  65,  66 
Parafolliculitis,  176 
Paraldehyd,  744 
Parallax  test  in  glaucoma,  399 

of  ocular  muscles,  74 
Parallel  rays,  22 
Paralysis,  accommodation,  65 
convergence,  595 
dilatator,  63 
divergence,  595 
oculomotor,  58() 
recurrent,  590 
of  external  rectus,  5S1 
of  exterior  ocular  muscles,  580 

congenital,  591 
of  inferior  oblique,  584 

rectus,  584 
of  interior  ocular  muscles,  595 
of  internal  rectus,  5.S2 
of  ocular  gyration,  594 
of  orbir;ularis,  190 
of  Hjjhiiicter,  (i2 
of  superior  oljlique,  585 
rectus,  583 
Paralytic  ectroijioii,  190 
miosis,  <>2,  03 
mydriasis,  <)2 
|)tosis,  190 
Htrabismus,5S0 
ParasiteH  in  anterior  chamber,  317 
sitic  conjunctivitis,  214 


Parenchymatous  keratitis,  287 

circumscribed,  295 
Paresis,  586 

Paretic  heterophoria,  610 
Parinaud's  conjunctivitis,  241 
Parker's  oj>eration  for  detachment  of 

retina,  708 
Partial  fugacious  amaurosis,  561 
Pa.steurization,  275 
Patient,  examination,  47 

position  of,  for  cataract  extraction, 

728 
preparation  of,  for  cataract  extrac- 
tion, 720 
Pediculus  pubis  in  eyelashes,  178 
Pedunculated   flaps   for  repair  of  dis- 
j)laced    eyelids    and    loss    of  hd  sub- 
stance, 075 
Pellidol,  277 

Pemphigus  of  conjunctiva,  256 
Pencil,  98 
Pepsin.  262 

Perception,  Ught,  qualitaltive,  67 
limit  of,  35 
of  light,  88 
Perforation  of  eye,  double,  318 
of  sclera,  317 

after  tenotomy,  749 
Peribulbar  epithehoma  of  conjunctiva, 

252 
Pericorneal  injection,  327 
Perineuritis,  528 

Periodic     hyperplastic     conjunctivitis, 
225 
iritis,  340 
Periostitis  of  orbit,  631 

syphilitic,  631 
Peripheral  annular  infiltration  of  cornea, 
300 
optic  neuritis,  518 
Perimeter,  83,  84 
electric-light,  84 
hand,  84 

self-registering.  84 
Perimetry,  small  object,  404 
Perithelioma  of  choroid,  389 
Peritomy,  241,  202 
Perivasculitis,  409,  497,  498  • 

Permanganate  of  potassium,  2U>,  218, 

23S,  2()2,  1)27,  727 
Peronin,  ().")S 
Peroxid  of  iivdrogen,  206,  219,  628 

in  i)()\vdi'r  Iturns,  198 
Persistent  hyaloid  artery,  459 

pupillary  meml)rane,  324 
Peter's  hand  campimeter,  83 
Petit,  bacillus  of,  2t»0 
Pfeiffer's  l)acillus,  204 

capsuiated  liacillus,  2()0 
IMiak. .crisis,  7  M 
l'h;ik<il\sis  in  lUNopia.  142 
I'lilcbitis  (.r  orbitMl  ycius,  034 
I'hlegmoii,  170 
of  orbil,  633 
i'lilycla'nfi  pallida,  22a 
I'lilyctcnular  conjunctivitis,  224 


INDEX 


817 


Phlyctenular  keratitis,  259 

keratoconjunctivitis,  259 

marginal  keratitis,  260 

ophthalmia,  224 

pannlis,  261 

ulcer,  260 
Phorometer,  Steven's,  77 
Phosgene  gas,  effects  of,  245 
Phosphates,  633 

crystalhzed,  456 
Phosphorus,  536 
Photometer,  68 
Photometric  tvpes,  68 
Photophobia,  328 

in  cataract,  429 

in  retinitis,  465 
Photophthalmia,  560 
Photopia,  68 
Photopsies,  373 
Phototherapy,  276 

in  corneal  opacities,  281 

Phthiriasis,  178 

Phthisis  bulbi,  290,  349,  396 

essential,  396 

from  choroiditis,  386 

Physiologic  astigmatism,  146 

cup,  104,  106 

excavations  of  optic  nerve,  105 

salt     solution.     See     Salt     solution, 
physiologic. 
Picric  acid,  178 
Piebald  irides,  53 

Pigment  degeneration  without  pigment, 
486 

spots  on  conjunctiva,  253 
Pigmentary  degeneration  of  retina,  484, 
488 

macular  retinal  degeneration,  487 
Pigmentation  of  cornea,  310 
peripheral,  310 
hematogenous,  322 
xenogenous,  322 

of  optic  nerve-fibers,  congenital,  516 

of  retina,  465,  490 

of  sclera,  congenital,  322 
Pigmented  choroiditis,  379 
Pilocarpin,    41,   62,    63,    91,    216,    271, 
287,  303,  312,  314,  339,  354,  367, 
380,  418,  419,  421,  426,  454,  456, 
466,  494,  554 

hydrochlorate,  418 

in  glaucoma,  418,  419 

in  scleritis,  312,  314 
Pimple  ulcer,  264 
Pince-ciseaux  of  de  Wecker,  697 
Pinguecula,  249 
Pink  eye,  202 
Pits,  corneal,  302 

Pituitary    body    disease,    visual    phe- 
nomena in,  562 
Pituitrin,  456 
Pix  hquids,  172 
Placido's  disk,  50 

Plague,  squirrel,  conjunctivitis,  208 
Plane  mirror,  93 

skiascopy  with,  117 
52 


Planoconcave  lens,  30 
Planoconvex  lens,  30 
Plant  hairs,  conjunctivitis  from,'  244 
Plasmoma  of  lacrimal  sac,  626 
Plastic  conjunctivitis,  221 

iridochoroiditis,  342 

operations,  675 
on  eyeUds,  674 
Pneumobacillus,  266 
Pneumococcus,  200,  266,  350,  624,  626 

conjunctivitis,  203 

of  Frankel-Weichselbaum,  386 

serum,  274 
Podophyllin,  conjunctivitis  from,  244 
Point,  far,  of  convergence,  46 

of  eye,  37 

near,  of  convergence,  46 
of  eye,  37,  38 

of  reversal,  117,  118 
Poisonous  gas  conjunctivitis,  245 
Polar  cataract,  438 
Poles  of  eye,  146 
Polycoria,  324 
Polvopia  in  cataract,  430 
Polypi  of  antrum  of  Highmore,  647 

of  orbit,  639 

of  puncta  lachrymaUa,  622 

of  sphenoid  sinus,  646 
Porus  opticus,  105 
Posey    and    Schwenk's    operation     to 

enlarge  contracted  socket,  681 
Position  of  eyes,  92 

of  patient  for  cataract  extraction,  728 
Positive  aberration,  122 
Posterior  polar  cataract,  374 

sclerotomy,  700 

staphyloma,  384 
Postvariolous  ulcer  of  eyelid,  172 
Potassic  fluorescide,  51 
Potassium  iodid.     See  lodid. 

permanganate.     See  Permanganate. 
Powder  grains  in  cornea,  304 
Power  of  accommodation,  38 
Precorneal  iridotomy,  694 
Pregnancv,    albuminuric    retinitis    in, 
474,  476,  477 

amblyopia  during,  551 
Prelacrimal  sac  abscess,  623 

cysts,  624 
Prentice's  method  of  numbering  prisms, 

20 
Preretinal  hemorrhages,  495 
Presbyopia,  41,  157 

age  and,  157 

causes,  157 

correction  of,  157 

glasses  in,  158 

near  point  in,  158 

reading-glasses  for,  159 
Presenile  cataract,  428,  436 
Pressure  pulse  of  retinal  arteries,  106 
Pretended  amblyopia,  557 
Primary  optic  centers,  565 

position  of  eyes,  573 

visual  ganglia,  565 
Prince's  method  of  advancement,  752 


818 


INDEX 


Principal    focus    of    concave    lens,    25 

of  convex  lens,  23 
Prism  tests  of  ocular  muscles,  75 
Prism-convergence,  76,  57") 
Prism-diopters,  20 

and    centrad,   relative  values  of,   20 

and  meter  angle,  relations  of,  20 
Prism-divergence,  70,  575 

test  for,  76 
Prism osphere,  615 
Prisms,  18 

adverse,  614 

angle  of  deviation,  19 

apex  of,  18 

base  of,  18 

Dennett's  method  of  numbering,  19 

de\'iation  produced  b}',  19 

exercises  with  in  heterophoria,  614, 
615 

handicap,  614 

Herschel,  77 

numbering  of,  19 

overcoming,  575 

Prentice's  method  of  numbering,  20 

prescription  of,  in  heterophoria,  615 

refracting  angle  of,  18 

refraction  through,  18 

relieving,  614 

revolving,  77 

rotary,  Risley's,  76,  77 

testing  with  in  heterophoria,  76 
Prol)e  and  spatula,  694 
Probes,  lacrimal,  758 

introduction  of,  757 
Prodromal  myopia,  429 
Proflavine,  712 
Progressive  optic  atrophy  with  scotoma, 

564 
Prolapse  of  iris  after  cataract  extraction, 
742 

of  lacrimal  gland,  spontaneous,  620 
Proliferating  chorio-retinitis,  481 

retinitis,  480 

uveitis,  364 
Pro[)tometor,  92 

ProF)tosis,    92,    630.     See    also    Exoph- 
thalmos. 
Prosthesis,  operations  for,  in  cicatrical 

orbital  sockets,  ()79 
Protargol,  206,  207,  213,  215,  216.  219, 
221,  222,  227.  238,  270,  277,   628 

argyrosis  from,  258 
Protein,  foreign,  in  eye  infections,  277 
Protiodid  of  iiiercury,  354 
Protractor  for  lens  testing,  164 
Protrusion  of  eyeball,  636,  (537 
Prowazek  bodies,  231,  232 
Prowazek-llalberstiiilter  bodies,  232 
Provoked  conjunctivitis,  245 
Pseudocolohoma  of  iris,  325 
Pseudoglioma,  3S5,  451 
P.seudo-isocliromntic  plates  of  Stilling, 

71 
pBCudomembranous  conjunctivitis,  221 

recurring,  222 
Pseudonystagmus,  617 


Pseudopterygia,  249 
Pseudoptosis,  190 

Pseudotuberculosis  of  conjunctiva,  246 
Psorophthalmia,  175 
Pterygium,  248 
congenital,  16S 
excision  of,  683 
Knapp's  operation  for,  683 
j        McReynolds'  operation  for,  683 

operations  for,  683 
!       transplantation,  683 
Ptosis,  Bowman's  operation  for,  661 
congenital,  169 
Elschnig's  oj)eration  for,  661 
Everbusch's  operation  for,  661 
Fergus'  operation  for,  664 
Gillet  de  Grandmont's  operation  for, 

661 
Harman's  operation  for,  661 
Hess'  operation  for,  664 
i       lipomatosis  of  eyelids.  181 
morning,  243 
Motais'  operation  for,  665 
Mules'  operation  for,  661 
of  eyelids,  190 
operations  for,  660 
Pagenstecher's  subcutaneous  thread 

operation  for,  661 
Panas'  operation  for,  661 
paralytic,  190 

Sourdille's  operation  for,  665 
sympathetic,  63 

Tansley-Hunt     operation     for,     662 
Wilder's  operation  for,  664 
Wolff's  operation  for,  661 
Worth's  operation  for,  661 
Pulley  suture,  752 
Pulsating  exophthalmos,  636,  640 
Pulsation  in  retinal  blood-vessels,   106 
Pulvinar  of  thalamus,  565 
Puncta  iachrymalia,  anomalies  of,  ac- 
quired, 622 
congenital,  622 
malposition  of,  622 
polyp  of,  622 
stenosis  of,  622 
streptothrix,  622 
Punctate  degeneration  of  cornea,  familv, 
298 
keratitis,  351 
Punch  forceps,  sclerectomy   witli.   702 
Punctum    proximum,    37,    38,    70,    SO 
in  myopia,  140 
remotum,  37,  70 
Puncture,  lumbar,  in  optic  neuritis,  527 
of  corpus  (•.'liiosum  in  optic  neuritis, 
.527 
I'uiiktal  lens,  31 
I'up'l.  53 

adapted  width  of.  54 

ag»!  and,  51 

.\rgyll  Hobert.son,  (>.3 

jussociated  action  of,  56 

cat-like,  54 

color  of,  in  cataract,  430 

c«)ntraction  of,  61,  62,  327 


INDEX 


819 


Pupil,  convergence  anomalies  of,  64 
dilatation  of,  61 
paradoxic,  65,  66 
reflexes  of,  57 
dilator  muscle  of,  58 
exclusion  of,  329 
immobility  of,  63 
in  cataract,  430 
in  glaucoma,  397 
in  hemianopsia,  570 
in  optic  nerve  atrophy,  532 
measurement  of,  54 
muscles,  55 

myotonic  movement  of,  65 
neurotonic  convergence  reaction,  65 
occlusion  of,  329 

paralysis  of  sphincter  muscles  of,  62 
position  of,  54 
reaction,  55 

accommodation,  56,  61 
cerebral  cortical,  57,  61 
convergence,  56,  61 
neurotonic,  65 
paradoxic,  66 
orbicularis,  57 
pain,  57 

paradoxic,  65,  66 
special,  67 
Westphal-Piltz,  57 
reflex  action  of,  55 

cerebral  cortex,  57,  61 
consenual,  light,  56,  60 
dilatation,  57 
direct  Ught,  55,  59,  60 
explanation  of,  57 
Gifford-Galassi,  57 
Haab's,  57,  61 
immobiUty  of,  63 
indirect,  56,  60 
hd-closure,  57 
Ught,  55,  59,  60 
of  imagination,  57 
palpebral,  51,  57,  65 
relaxation,  57 
sensory,  57 
skin,  57,  61 
retinal  adaptation  to  light  and,  54 
seclusion  of,  329 
sex  and,  54 
size  of,  53,  54 
sphincter  muscle  of,  57 
unequal,  65 

varying  inequality  of,  65 
width  of,  54 
Pupillary  dilatation,  paradoxic,  65,  66 
inaction,  hemiopic,  65 
membrane,  328 
movements,  55 
muscles,  58 
persistent,  324 
phenomena,  65 
reactions,  paradoxic,  65,  66 
rigidity,  62 
Pupillometer,  54,  55 

Haab's,  54 
Pupil-reflexes,  55 


Purulent  conjunctivitis,  208 
in  young  girls,  216 

iritis,  385 

keratitis,  265 

ophthalmia,  217 
Pus  in  vitreous,  451 
Pustular  ophthalmia,  225 
Pustule,  malignant,  of  eyelid,  170 

migratory,  260 
Pyocyanase  in  hypopyon  keratitis,  275 
Pyocyaneus  bacillus,  275 
Pyoktanin,  185 

blue,  628 
Pyorrhea  alveolaris,  340,  350,  355,  379 
Pyramidal  cataract,  211,  438 

Quadrant  homonymous  anopsia,  568 
QuagUno's  operation  for  glaucoma,  699 
Quinin,  172,  174,  178,  206,  219,  224,  225, 
262,  278,  286,. 296,  315,  341,  387, 
559,  635 
amaurosis,  553 
amblyopia,  553 
and  iron,  628 
sulphate,  174 

Rabitt's  bile,  276 

conjunctiva,  transplantation  of,  256 

cornea  transplantation,  282 
Radian,  19 

Radium,  179,  180,  183,  185,  254,  277, 
536,  637,  638 

bromid,  254 

in  angioma  of  eyeUds,  180 

in  carcinoma  of  eyeUds,  185,  186 

in  cataract,  444 

in  epithehoma  of  eyehds,  186 

in  gUoma,  512 

in  granular  conjunctivitis,  240 

in  optic  atrophy,  536 

in  trachoma,  240 

in  uveitis,  355 

in  vernal  conjunctivitis,  228 

in  xanthelasma,  182 
Ramsay's     modification     of     Worth's 

amblyoscope,  605 
Range  of  accommodation,  38 
Raphanic  cataract,  435 
Rav's  modification  of  Mules'  operation, 

713 
Rays,  21 

axial,  98 

convergent,  22 

divergence  of,  21 

divergent,  22 

of  light,  17,  20 

parallel,  20 

significance  of  different  kinds,  22 
Reactions,  pupil,  55 
Readjustment  for  squint,  750 
RecUnation  for  cataract,  722 
Rectus,  external,  572.     See  also  Exter- 
nal rectus. 

inferior,  572.     See  also  Inferior  rectus. 

internal,     572.     See     also     Internal 
rectus. 


820 


INDEX 


Rectus,  superior,  572.    See  also  Superior 

rectus. 
Recurrent  iritis,  337 

oculomotor  paralysis,  590 

retinal  hemorrhage,  455 

subconjunctival  hemorrhage,  249 
Red  oxid  of  mercury,  177 

vision,  560 
Red-blindness,  547 

complete,  09 
Red-free  light,   ophthalmoscopy  with, 

111 
Red-green  blindness,  547 
Reese's  forceps,  754 

muscle-resection  operation,  754 
Reflection,  93 
Reflex  amblyopia,  549 

foveal,  108 

inactivity,  63 

iridoplegia,  63,  64 
unilateral,  64 

lacrimal,  51 

Ught,  105 

macular,  109 

palpebral,  51 

pupil,  55 

retinal  lid-closure,  51 
Reformed  artificial  eye,  712 
Refracting  angle  of  prisms,  18 
Refraction,  17 

abnormal,  126 

angle  of,  18 

determination  of,  by  ophthalmoscope, 
111,  115 

index  of,  17 

normal,  126 

ophthalmoscope,  95 

skiascopy       for,       117.     See       also 
Skiascopy. 

through  a  prism,  18 
Refractive  power  of  lens,  28 
Refractometer,  117 

Thomson's,  117 
Region  of  accommodation,  38 
Reid  ophthalmometer,  116 
Relapses  of  iritis,  331 
Relapsing  erosion  of  cornea,  305 

hcri)cs  corncffi,  295 

traumatic  keratitis  l)ull(>sa,  305 
Relative  accommodation,  46 
Relaxation-r.'ficx  of  jjupils,  57 
Relieving  prism,  614 
Renal  retinitis,  473,  474 
Resection  of  sclera  for  rolinal  detach- 
ment, 708 

of  temporal  wall  of  orbit,  720 
Re.sorcin,  177 

Retention  cyst  of  ethmoid  simis,  644 
of  eyelids,  196 
of  moiltomian  glands,  183 
of  sweat-glands,  196 
true  lymnhatic,  .309 

theory  of  (rlironic  glaucoma,  412 
Reticular  ojjacilics  of  cornea,  299 
Retina,  lOS 

adaptation  of,  54,  68,  88 


Retina,  adaptation  of,  delayed,  88 
anemia  of,  461 
anesthesia  of,  462,  561 
symptoms,  462 
traumatic,  506,  561 
treatment,  463 
aneurysms  in,  501 
angioid  streaks  in,  499 
angiomatosis  of,  501 
angiosclerosis  of,  499 
apoplexy  of,  494.     See  also  Retina, 

hemorrhages  in. 
arteries  of,  105 
atrophy  of,  465 

in  retinitis,  469 
blood-vessels  of,  105,  108 
capillary  congestion  of,  460 
central  artery  of,  embolism  of,  601. 
See  also  Retina,  central  artery 
of,  obi'tructioii  of. 
obstruction  of,  501 
causes,  504 
ciUoretinal  vessel  in,  502,  503, 

504 
diagnosis,  504 
field  of  vision  in,  503 
intra-ocular  tension  in,  503 
ischemic  necrosis  in,  502 
macula  in,  502 
massage  in,  505 
opacity  in,  502 
papilla  in,  502 
prognosis,  504 
sjTiiptoms,  501 
treatment,  505 
vision  in,  502 
veins  of,  thrombosis  of,  505 
causes,  505 
progno.sis,  505 
secondary  glaucoma  in,  505 
symptoms,  505 
treatment,  506 
changes  in  from  electric  light,  509 

from  sunlight,  509 
color  of,  lOS 
congestion  of,  461 

in  hyperopia,  129 
cyanosis  of,  4t)3 
cysticercus,  512 
cysts  of,  512 
degeneration  of.  pigmentarv  macular, 

4S7 
detachment  of,  490 
causes,  491 
color  of,  490 
complete,  490 
congenital,  492 
diagnosis,  493 
dilTiision  theory  of,  492 
tidds  of  vision  in,  493 
flat,  491 
from    discasos   of    na.sal    .'icoo-ssory 

sinuses,  t>49 
hemorrhagic,  492 
liereditary,  492 
mechanical  theory  of,  493 


INDEX 


821 


etina,  detachment  of,  mechanism,  492 

operations  for,  494,  708 

partial,  490 

prognosis,  493 

retraction  theory,  492 

symptoms,  490 

traumatic,  492 

treatment,  494,  496 

trephining  sclera  for,  708 
diseases  of,  460 
edema  of,  466,  506,  522 
entozoa  in,  458 
family  cerebral  degeneration  of,  with 

macular  changes,  514 
glioma  of,  510 

diagnosis,  511 

endophytum  of,  510 

exophytum  of,  510 

fungus  hsematodes  in,  511 

prognosis,  512 

recurrence  of,  510 

rosettes  in,  510 

stages  of,  510 

treatment,  512 
hemorrhages  in,  494 

causes,  495 

flame-shape,  465 

prognosis,  496 

recurrent,  455 

subhyaloid,  495,  496 
hyperemia  of,  331,  460 
hyperesthesia  of,  461 

causes,  461 

treatment,  462 
increased  redness  of,  460 
inflammation   of,  464.     See  also 

Retinitis. 
irritation  of,  461 
ischemia  of,  461 
light-sense  of  periphery  of,  88 
macular  atrophy  of,  515 
massive  exudation  of,  499 
neuro-epithelioma  of,  510 
operations  for  detachment  of,  708 
periphery  of,  acuteness  of  vision  of, 
88  _ 

functions,  86 

hght-sense  of,  88 
pigment  striae  of,  499 
pigmentary     degeneration     of,     484. 

See     also     Retinitis,     pigmentosa. 
pigmentation  of,  490 

secondary,  377 
rupture  of,  509 
sclerosis    of,    without    formation    of 

pigment,  486 
secondary  pigmentation  of,  377 
senile  macular  atrophy  of,  515 
serous  detachment  of,  490 
shot-silk,  108 

snowbank  appearance  in,  473 
spontaneous  pulsation  of  veins  of,  106 
traumatic    anesthesia    of,    506,    561 
traumatisms  of,  506 
tuberculosis  of,  482 
undue  capillarity  of,  460 


Retina,  veins  of,  105,  108 
vessels  of,  changes  in,  497 

distribution  of,  106 
Retinal  arterial  pulse,  106 

artery  central,  aneurysm  of,  501 
embohsm  of,  50  i 
intermittent  closing,  504 
spasm  of  walls  of,  504 
thrombosis  of,  501 
asthenopia,  556 
exudation,  massive,  499,  500 
image  in  ametropia,  35 

in  emmetropia,  34 

in  hyperopia,  35 

in  myopia,  35 
irritation,  470 
hd-closure  reflex,  51 
pigment  strise,  499 
Retinitis,  331,  464 
acute,  466 
albuminuric,  473 

blue-blindness  in,  474 

causes,  474 

comphcations,  476 

course,  475 

date  of  occurrence,  474 

degenerative,  474 

diagnosis,  477 

exudative,  474 

forms  of,  474 

frequency,  474 

hemorrhages  in,  473  474 

in  pregnane}^,  474,  476,  477 

inflammatory,  474 

neuritic,  474 

papilhtic,  474 

pathologic  anatomy,  475 

prognosis,  475,  476 

star-shaped  figure  in,  473 

symptoms,  473 

treatment,  478 

unilateral,  474 

violet-bhndness  in,  474 

vision  in,  473 
angiopathic,  472 
areas  of  exudation  in,  464 
atrophicans  centralis,  515 
atrophy  in,  465,  466 
blood-vessels  in,  464 
cachectic,  496 
causes,  464 

central  relapsing,  467,  470 
chronic,  466 
circinata,  483 
circumscribed,  464 
classification,  467 
chnical  types,  467 
comphcations,  466 
course,  466 
diabetic,  464,  478 

central  punctate,  479 

exudative,  478 

hemorrhagic,  478 

treatment,  480 
deep,  467 

prognosis,  467 


822 


INDEX 


Retinitis,  diagnosis,  466 
diffuse,  464,  466 
distortion  of  vision  in,  465 
edema  of,  466 
electric,  509 
exudative,  499 
field  of  vision  in,  465 
flame-shape  of,  465 
hemorrhages  in,  465 
hemorrhagic,  464,  472 

causes,  472 

prognosis,  472 

treatment,  472 
hemorrhagica  externa,  499 
leukemic,  480 

loss  of  transparency  in,  464 
macropsia  in,  465 
macularis,  470 
metamorphopsia  in,  465 
metastatic,  471 
micropsia  in,  465 
nerve-head  in,  465 
nyctalopia,  559 
oi"  angiosclerosis,  498 
of  Bright's  disease,  473 
of  pregnancy,  476,  477 
pain  in,  465 

parenchymatous,  464,  466 
pathologic  anatomy,  464 
photophobia  in,  465 
pigmentation  in,  465 
pigmentosa,  484 

abiotrophy  in,  488 

atypical  varieties,  486 

causes,  487 

compUcations,  487 

contraction  of  vessels  in,  484 
of  visual  field  in,  485 

course,  489 

depreciation  of  central  vision   in, 
485 

diagnosis,  488 

heredity  in,  487 

nerve-head  in,  484 

night-V)nndness  in.  485 

nystagmus  in,  485 

of  macula,  487 

opacities  in,  484 

pathologic  anatomy,  487 

pathology,  487 

pigmentation  in,  484 

prognosis,  489 

ring  scotoma  in,  485 

symptoms,  484 

treatment,  489 

wainscoted  fundus  in,  484 
primary,  4()4 

suppurative,  472 
I)r()gn().siH,  '!('>('» 
l)roliferating,  480 

causes,  481 

treatment,  482 
p\iiictatH  albescens,  486 
punctate,  4S() 
renal,   4()4,   473.     See  also   Hdinitis, 

albuminuric. 


Retinitis,  Roth's  septic,  471 

secondary,  464 

serous,  464,  466 

septic  of  Roth,  471 

simple  syphilitic,  467 

simplex,  466 

solar,  509 

stellate,  478 

striata,  483 

sjTnptoms,  464 

syphilitic,  464,  467 
atrophy  in,  469 
course,  470 

date  of  occurrence,  469 
prognosis,  470 
ring  scotomas  in,  469 
symptoms,  468 
treatment.  470  • 

tortuosity  of  vessels  in,  464 

treatment,  466 

typical  renal,  474 

types,  466 

varieties,  464 

visual  acuteness  in,  465 

vitreous  opacities  in,  466 

with  exudations,  467,  469 

with  hemorrhages,  467,  469 

with  mihary  aneurysms,  501 
Retinochoroiditis,        374.     See        also 
Choroidoreiin  itis. 

hemorrhagic  central,  380 

juxtapapillaris,  378 
Retinoscopy,  117.     See  also  Skiascopy. 
Retraction  of  eyeball,  651 
Retrobulbar    neuritis,    536.     See    also 

Optic  Neuritis. 
Retrotarsal  fold,  excision  of,  in_  trach- 
oma, 687 
Reversal,  point  of,  117,  118 
Rhagades  on  eyelids.  179 
Rheumatic  iritis,  336 
Rheumatism,  336 
Riband-like  keratitis,  300 
Rice-starch,  174 
Riders  in  zonular  cataract,  437 
Rigidity,  pupillary,  62 
Ring  abscess,  217 

after  cataract  extraction,  740 
of  cornea,  306 

choroidal,  104 

connective-tissue,  104 

sarcoma,  357 

scleral,  104 

scotoma  in  retinitis  pigmentosa,  485 

Vossius,'  441 
Ring's  ocular  mask,  733 
Risley's  rotary  prism,  76,  77 
Rod  test  for  ocular  musclcis,  70,  78,  79 
Rodent  ulcer,  267,  273 
of  cornea,  268 
of  eyelids,  183 
Rod-screen   test  for  ocular  muscles,  SO 
Hoiino'   nasal  step    in 'glaucomn,  W.], 

104 
Uontgen  ray.     See  x-Rai/K. 
Rosacea  keratitis,  280 


INDEX 


823 


Roseola,  332 

Rotary  prism,  Risley's,  76,  77 

Rotation,  center  of,  41 

of  eyeball  around  visual  line,  573 
Roth's  septic  retinitis,  471 
Rupture  of  choroid,  385 

of  cornea,  317 

of  retina,  509 

of  sclera,  317 

spontaneous,  of  glaucomatous  eyeball, 
407 

Saccharinate  of  sodium,  293 
Saddle  nose,  628 
Ssemisch's  ulcer  of  cornea,  265 
Ssemisch-Guthrie  section,  690 

Schwenk's  modification,  690 
Sago-grain  granulations,  235 
Salicylate  of  eserin,  419 

of  mercury,  335 

of  sodium,  174,  286,  312,  338,  354, 
366,  419,  423,  494,  741 

of  strontium,  338 
SalicyUc  acid,  190,  227,  278,  312,  338, 
539,  592,  628 
amblyopia  from,  553 
SaUne  waters,  278 
Salmon  patch  of  Hutchinson,  288 
Salol,  278,  314 
Salt    solution,    physiologic,    354,    380, 

419,  445,  454,  494,  627,  654,  678,  689, 

694,  709,  724,  725,  727,  728 
Salvarsan,  179,  293,  294,  335,  354,  357, 

368,  380,  419,  470,  471,  526,  536,  592, 

632 
Salvarsanized  serum,  536 
Samoan  conjunctivitis,  208 
Santonin,  556 
Sarcinse,  200 
Sarcoma  of  anterior  chamber,  347 

of  antnmi  of  Highmore,  647 

of  choroid,   388.     See  also   Choroid, 
sarcoma  of. 

of  cihary  bod}',  357 

of  conjunctiva,  253 

of  cornea,  307 

of  ejjehds,  181,  183 

of  iris,  344 

of  lacrimal  sac,  626 

of  orbit,  637,  638,  639 

of  sclera,  316 
Savage's  method  for  shortening  tendons, 
756 

orthoptic  exercises,  614 
Scalds  of  cornea,  306 
Scar  keratitis,  280 
Scar-fibroma  of  cornea,  307 
Scarifier,  three-bladed,  686 
Scarlet  red  in  corneal  ulcer,  277 
Scarpa,  staphyloma  of,  posterior,  315 
Schiotz'  tonometer,  90,  91,  397 
Schiotz  and  Javal  ophthalmometer,  116, 

763,  765 
Schmidt's  method  of  enucleation,  710 
School  folhcles,  228 

foUiculosis,  228 


School  myopia,  134 
Schweigger's  hand  perimeter,  84 

method  of  advancement,  752 
Schweinitz's  enucleation  method,  71(1 
modification  of  amblyoscope,  605 
test  for  binocular  vision,  609 
Schwenk's    modification    of     Guthrie- 

Ssemisch  section,  690 
Schwenk  and  Posej^'s  operatio     to  en- 
large contracted  socket,  681 
Scissors,  iris,  694 
Sclera,  abscess  of,  316 
blood-vessels  of,  49 
brawny  infiltration  of,  315 
congenital  pigmentation  of,  322 
cysts  of,  316 
diseases  of,  311 
ectasia  of,  315 
foreign  bodies  in,  318 
inflammation  of,  311.     See  also  Scler- 

itis. 
injuries  of,  316 
prognosis,  317 
symptoms,  317 
treatment,  318 
operations  on,  699 
perforation  of,  317 
after  tenotomy,  749 
in  enucleation  of  eyeball,  711 
pigmentation  of,  congenital,  322 
resection  of,  for  retinal  detachment, 

708 
rupture  of,  317 
staphyloma  of,  315 
trephining,  for  detachment  of  retina, 

708 
tumors  of,  316 
ulcers  of,  316 
wounds  of,  316 
Scleral  crescents,  385 

puncture  in  glaucoma,  420 
ring,  104 
trephining,  703 
Sclerectomy  combined  with  iridectomy,. 
700 
simple,  701 

trephines,  Stephenson's,  705 
with  punch  forceps,  702 
with  trephine,  703 
Scleritis,  311 
annular,  315 
causes,  313 
gummatous,  313 
hyperplastic,  312 
indurative,  glaucoma  from,  414 
nodular,  312  , 

pathology,  313 
posterior,  315 
scrofulous,  314 
treatment,  314 
tuberculous,  313 
Sclerochorioretinitis,  intra-uterine,  309 
Sclerocorneal  trephining,  703 
Sclerokeratitis,  313 
Sclerokerato-iritis,  314 
treatment,  314 


824 


INDEX 


Sclerophthalmia,  309 
Sclerosing  trachoma,  234 
Sclerosis,  disseminated,  538 

of  choroid,  primary,  381 

of  choroidal  vessels,  380,  381 

of  cornea,  302,  309 

of  retina  without  formation  of   |)i;;- 
ment,  486 
Scleroticochoroiditis,    374 

anterior,  384 

from  myf)pia,  135 

posterior,  384 
Sclerotics  blue,  323 
Sclerotizing  keratitis,  297 
Sclerotome,  700 
Sclerotomy,  699 

anterior,  G99 

as  sul)stitute  for  iridectomy,  423 

coml)inetl  with  electrolytic  punctures 
in  retinal  detachment,  708 

in  glaucoma,  421 

in  malignant  glaucoma,  423 

in  uveitis,  355 

internal,  700 

lines  of  incision  in,  700 

posterior,  700 
Scopolamin,    123,    124,    174,   239,   286, 

334,338,354,367,705 
Scopolamin-morphin  anesthesia,  656 
Scotomas.  88,  89,  509 

absolute,  89 

annular,  562 

in  glaucoma,  404 

Bjerrum's,  403,  404 

central,  89,  563 
exhaustion,  562 

color,  89 

complimentary  color  test  for,  89 

deUmitatioii  of,  89 

detection  of,  90 

extinction  test  for,  89 

in  glaucoma,  404 

measuring,  90 

negative,  89 

I)aracentral,  89,  532,  563 

IK'rijjapiilarv,  89 

peripheral,  89,  532 

positive,  89 

relative,  89 

ring,  89 

ring-shaped,  502 

Konne's  nasal  step  in,  404 

special  instruments  for  detecting  and 
measuring,  90 

stationary  optic  atrophy  with,  5()3 

van  der  Hotive's,  ()49 

with  central  amblyopia,  5(52 

with  optic  neuritis,  564 

with   progressive  optic  atmpliy,   561 
Scotometers,  90,  404 
Scotopia,  (58 
Screen  test  for  heteroplioria,  (512 

for  ocular  iiiiiscjcs,  74 
»Scr<)fulous   infiltrations  of  cornea,   •_'()! 

iritis,  341 

opiithulmia,  224 


Scrofulous  scleritis,  314 
Sebaceous  cysts  of  eyehds,  196 
Seborrhea,  195 

of  lid-l)order,  175 
Seborrhma  nigricans,  196 
Second  sight,  135,  429 
Secondary  axes,  26 

iritis,  342 

l)osition  of  eyes,  573 
Seidel's  method  of  local  anesthesia,  659 

sign,  403 

in  glaucoma,  405 
Semi-albinism,  371 
Senile  areolar  atrophy  of  choroid,  380 

cataract,  436 

ectropion,  operation  for,  670 

guttate  choroiditis.  381 

macular  atrophy  of  retina,  515 

marginal  atrophy,  299 
SensibiUt\'  of  corneas.  51 
Sensory  reflex  of  pupil,  57 
Septic  conjunctivitis,  241 

retinitis  of  Roth,  471 
Serous  detachment  of  retina,  490 

iritis,  342,  349 
Serum,  antidiphtheritic,  242,  275,  740 

antigonococcus,  216,  219 

antipneumococcus,  274 

antistreptococcus,  275 

Deutschmann's,  275 

jequiritol,  240 

pneumococcus,  274 

streptococcal,  222 

treatment  of  corneal  ulcer,  274 

yeast,  275 
Shadow  test,  117.     See  also  Skiascopy. 
Shahan  thermophore,  276 
Shattered  eye,  317 
Shell-shock,  amblyopia  in.  550 

vision  in,  550 
Shooting  eye,  550 
Short      sightedness,      127.     See      also 

Myopia. 
Shot-silk  retina.  108 
Shrinking  of  conjunctiva,  essential,  256 
Sideroscoi)e  method  of  locating  foreign 

bodies,  319 
Siderosis  bulbi,  322 

conjunctiva*,  258 
Siegrist's   method   of  local   anesthesia, 

658 
Sight,  17.     See  also  Vision. 

second,  135,  429 
Silver,  229 

catarrii,  213.     See  also  Nitrate. 

nitrate.     See  .Mlrale. 
Silverwire  arteries,  497 
Sinuses,  disea.ses  of,  643 
Sinusitis,  526 

Sinusoidal  current   in  atropliy  of  optic 
nerve,  C)'M\ 

galvanism    in   orbital   o|)tic   neuritis, 
51 1 
Sixth    nerve,    572.     See   also   Alniucens 

iicrrr. 
Skiumelry,  dynjimic.  12;5 


INDEX 


825 


Skiascopy,  93,  117 

in  astigmatism,  120,  122 

in  emmetropia,  120 

in  hyperopia,  120,  132 

in  myopia,  119 

measurement  of  accommodation  by, 

122 
with  concave  mirror,  118 
with  plane  mirror,  117 
Skin  graft,  dermic,  679 
epidermic,  679 
grafting,  operation  of,  679 
Thiersch's  method,  679 
in  symblepharon,  684 
preparation  of,  for  operation,  654 
reflex  of  pupil,  57,  61 
Skull  deformities,  optic  neuritis  from, 
525 
fracture    of,    hemorrhage   into   optic 
nerve  sheath  after,  549 
SUng-magnets,  321 
SUtting  canaliculus,  757 
Sloped  molar  of  Gifford,  290 
Smith's    (Col.    Henry)    operation    for 
cataract,  735 
(Homer     E.)     capsulotomj^     before 

cataract  extraction,  745 
(Priestley)  enucleation  method,  710 
keratometer,  51,  54 
tape  measurement  of  strabismus, 

601 
test  for  binocular  vision,  609 
for  malingering,  558 
Snellen's  artificial  eye,  712 
method  of  tenotomy,  748 
suture  operation  for  ectropion,  671 
test  for  mahngering,  557 
type,  35 
Snow-ball  opacities,  453 
Snowbank  appearance  of  retina,  473 
Snow-bUndness,  559 
Snydacker's  test  for  colors,  72 
Soaps,  ophthalmic,  177 
Sodium  chlorid,  494,  658,  629,  73 . 
citrate,  419 
iodid,  444 
nitrate,  435 
saccharinate,  293 
saUcylate,  367,  741 
sulphate,  281 
Solar  retinitis,  509 
Solution  operation  for  cataract,  722 
Sophol,  213,  216 

Sourdille's  operation  for  ptosis,  665 
Sozoiodolate  of  zinc,  207 
Spasm  of  accommodation,  in  hyperopia, 
128 
of  convergence,  595,  609 
of  eyehds,  189,  190,  191 
Spasmodic  esophoria,  596 

heterophoria,  610 
Spasmus  nutans,  618 
Spastic  accommodation,  328 
miosis,  63 
mydriasis,  62 
ptosis  of  eyelids,  189 


Spastic  strabismus,  609 
Spatula  and  probe,  694 
Spectacles,  163 

adjustment  of,  163 

stenopaic,  156 

telescopic,  143 

testing  of  lenses  in,  164 

treatment  of  strabismus  by,  602 
Spectroscope,  72 
Speculum,  eye,  693 
Sphenoid  sinus,  disease  of,  646 
empyema  of,  646 
hyperostoses  of,  646 
osteoma  of,  646 
polypi  of,  646 
Spheric  lenses,  30 
Sphincter,  paralysis  of,  62 

pupillse,  57 

rupture  of,  346 
Spinal  miosis,  63 

Spirochseta  palhda,  179,  332,  355,  378 
Spongy  exudate  after  cataract  extrac- 
tion, 741 
Spontaneous    disappearance    of    senile 
cataract,  442 

prolapse     of     lacrimal     gland,     620 
Spoon,  metal,  728 
Sporothrix  beurmannii,  178 
Sporotrichosis  of  conjunctiva,  242 

of  eyelids,  178 
Spot,    yellow,    108.     See   also    Macula 

lutea. 
Spring  catarrh,  226 

conjunctivitis,  225,  226 
Springing  mA'driasis,  65 
Squint,  73,  576.     See  also  Strabismus. 
Squinting  eye,  576 
Squirrel  plague  conjunctivitis,  208 
Standish     method     in     conjunctivitis 

neonatorum,  215 
Staphvlococcus,    171,    172,    177,    222, 
223,  266,  350,  386,  624 

albus,  200 

conjuncti\dtis,  201 

pyogenes  albus,  200,  225,  260 
aureus,  200,  225,  260 

vaccine,  354 
Staphyloma,  263 

annular  posterior,  384 

anterior,  211 
total,  211 

Berry's  operation  for,  691 

cihary,  316 

DeWecker's  operation  for,  691 

intercalary,  316 

of  amnion,  posterior,  315 

of  cornea,  278 

congenital  anterior,  309 

of  Scarpa,  posterior,  315 

of  sclera,  315 

operations  for,  691 

posterior,  138,  139,  315,  384,  517 
myopia  and,  139 

treatment  of,  282 

Ziegler's  keratectomy  for,  691 
Star,  lens,  146 


826 


INDEX 


Stationary  optic  atrophy  with  scotoma, 

563 
Stauungs-papille,  528 
Stellate  retinitis,  478 
Stellwag's  sign  in  exophthalmic  goiter, 

642 
Stenopaic  sUt,  152 

spectacles,  156 
Stenosis    of    puncta    lachrynialia,    622 
Stephenson's  sclerectomy  trephines,  705 
Stereocampimeter,  Lloyd's,  90 
Stereoscope,  603 
Stereoscopic  charts,  Haitz's,  90 
exercises  in  heterophoria,  616 
Stevens'  classification  of  heterophoria.s, 
73,  74 
chnoscope,  768 

instruments  for  tenotomy,  750 
method  of  tenotomy,  748 
phorometer,  77 
tenotomy,  749 
tropometer,  767 
StilUng's    pseudo-isochromatic    plates, 

71 
Stovain,  657 
Strabismus,  73,  576 
amblyoscope  in,  604 
angle  of,  600 
atropinization  in,  602 
concomitant,  596 

accommodation  in,  597 
alternating,  596 
amblyopia  in,  598 
bar  reading  in,  606 
causes,  597 
constant,  596 
convergence  in,  597 
educative  treatment,  603 
fusion  faculty  in,  598 
inequaUty  of  vision  in,  598 
innervation  in,  598 
monocular,  596 
occlusion  of  fixing  eye  in,  603 
operative  treatment  in,  606 
orthoptic  training  in,  603 
periodic,  596 
single  vision  in,  599 
spectacle  treatment,  602 
stereoscope  in,  603 
tenotomy  in,  006 
treatment,  602 
varieties,  596 

Worth's  amblyoscope  in,  604 
convergens,  576 
convergent,  43,  676,  582 

accommodation    and    convergence 

disturbances  as  cause,  597 
amblyoscope  in,  604 
angle  ganiina  in,  509 
atr<)i»iiiiziition  in,  (>()2 
bar  reading  in,  tiOd 
educative  treat mcnt  in,  ('>t).'{ 
in  hyperopia,  12S 
Javai's  controlled  rending  in,  606 
occlusion    of    fixing    eye    in,    603 
operative  treatment,  606 


Strabismus,  convergent,  orthoptic  train- 
ing in,  603 
results  of  operation  in,  608 
shape  of  eyeball  as  cause,  599 
spectacle  treatment  in,  602 
steroscope  in,  603 
tenotomy  in,  606,  607 
deorsum  vergens,  576 
divergens,  576 

divergent,  576,  577,  578,  583,  586 
concomitant,  glasses  in,  607 
operations  for,  608 
treatment,  607 
directly  periodic,  578 
inversely  periodic,  578 
myopia  and,  137 
downward,  579,  583 
dynamic,  73 
hooks,  747 

inversely  periodic  divergent,  578 
Landolt's  treatment  for,  603 
latent,  73 

measurement  of,  600 
angular  method,  601 
Smith's  tape  method,  601 
tangent  method.  600 
operations  for,  747 
paralytic,  580 

binocular  single  vision  in,  580 

carriage  of  head  in,  581 

complete,  580 

congenital,  591 

diagnosis  in,  586 

diplopia  in,  580 

field  of  vision  in,   580,   582,   585, 

586,  583,  584 
from   diseases   of   nasal   accessor}- 

sinuses,  649 
incomplete,  580 
method  of  examination  in,  586 
primarv    deviation    in,    580,    582, 

585,  586,  583,  584 
prognosis,  592 
secondary  deviation  in,  580,  582, 

583,  584.  585,  586 
symptoms,  580,  581 
treatment,  592 
varieties  of  diplopia  in,  581 
vertigo  in,  581 
spastic,  609 
suppressed,  73 
sursum  vergens,  576 
tentomv  for,  606,  607 
upward,  579,  585 
vertical,  608 
Strabisometer,  600 

Stramonium,  amblyopia  from,  539,  553 
Streptococcal  serum,  222 
Strei)toco<cus,  222,  223,  243,  266    350, 
3S6,  624 
diplitheria  of  conjunctiva,  222 
l)vogones,  171,  200,  626 
viridans,  350 
Streptothrix,  2(>6,  j^22 
Stretcliing  eyes,  375 
Striuj  of  refraction  in  cataract,   130 


INDEX 


827 


Striae,  retinal  pigment,  499 
Striate  clearing  of  corneal  opacities,  282 
Stricture,    lacrimal,    incision    of,    758 
Stricturotome,  Thomas',  758 
Strychnin,  172,  219,  278,  380,  420,  422, 

461,  489,  506,  536,  541,  552,  554,  559, 

613,  618 
Stye,  171 

in  hyperopia,  129 
Subacute  conjunctivitis,  204 
Subconjunctival  extraction  of  cataract, 
738 

hemorrhage,  recurrent,  249 

injections,  689 

in  corneal  ulcers,  275 

tenotomy,  Critchett's,  747 
Subduction,  572 

Subhyaloid  hemorrhages,  495,  496 
Subnitrate  of  bismuth,  262 
Subperiosteal  abscess,  631,  648 
Subretinal  cysticercus,  512 
Succinate  of  iron,  457 
Suction  curet,  724 

method  of  cataract  extraction,  724 
Suker's  enucleation  method,  709 
Sulphate  of  chromium,  284 

of  copper,  220,  229,  238,  239,  240, 
242,  686 

of  eserin,  303,  419,  496 

of  iron,  siderosis  from,  258 

of  magnesia,  620 

of  quinin,  222,  227 

of  zinc,  178,  206,  207,  220,  228,  238, 
706 
Sulphur,  195 

milk  of,  177 
Sunlight,  changes  in  retina  from,  509 
Superduction,  572 
Superficial  linear  keratitis,  296 
Superior    colliculus    of    corpora    quad- 
rigemina,  565 

oblique,  572 

paralysis  of,  586 

rectus,  572 

paralysis  of,  583 
Supernumerary  eyelid,  169 
Suppuration   of   wound  after  cataract 

extraction,  739 
Suppurative  keratitis,  267 
Suprarenal    capsule,    preparations    of, 
659 

extract,  200,  227,  243 
Suprarenin,  659 
Surgical  conus,  541 
Sursumduction,  test  for,  76,  77 
Sursumvergence,  76,  77,  575 

left,  77 

right,  77 

test  for,  77 
SutcUffe  ophthalmometer,  116 
Sutures,  655 

Kalt's  corneal,  738 

operation,    Snellen's,    for    ectropion, 
671 

pulley,  752 

tobacco-pouch,  712 


Swanzy's  method  of  advancement,  751 
Sweat-glands,  retention  cysts  of,  196 
Sweet's     x-ray     method    of    locating 

foreign  bodies,  768 
Swelling  with  catarrh,  207 
Swimming-bath  conjunctivitis,  204 
Sycosis  tarsi,  175 
Symblepharon,  167,  191 

operations  for,  684 

Teale's  operation  for,  684 

Thiersch's  method  of  skin  grafting 
in,  684  . 

transplantation  of  mucous  membrane 
in,  684 
Sympathectomy  for  glaucoma,  423 
Sympathetic  amblyopia,  361 

inflammation,    359.     See    also    Oph- 
thalmitis, sympathetic. 

iritis,  342 

irritation,  358 
causes,  358 
symptoms,  358 

ophthalmia,  358.     See  also  Ophthal- 
mitis, sympathetic. 

ophthalmitis,     358,     359.     See    also 
Ophthalmitis,  sympathetic. 

papilloretinitis,  360 

ptosis,  63 

uveitis,  360 
Sympathizing  eye,  359 
Symptomatic  conjunctivitis,  201 
Synchysis,  456 

scintillans,  456 
Syndrome,  Horner's,  63 
Synechia,  55 

annular  posterior,  328 

anterior,  278 
division  of,  699 

posterior,  327 
Synkinesis,  55 

accommodation,  56 
SyphiUs,  332 

acquired,  287,  290 

hereditary,  287,  334 

in  oculomotor  paralysis,  589 

of  ciliary  body,  356 

of  conjunctiva,  250 

of  eyelids,  178 

of  lacrimal  gland,  621 
Syphilitic  conjunctivitis,  250 

dacryo-adenitis,  621 

endarteritis,  468,  469 

hereditary  choroidoretinitis,  470 

iritis,  332 

keratitis,  287 

periostitis  of  orbit,  631 

retinitis,  467 

ulcers  of  eyehds,  187 
Syphiloma  of  ciliary  body,  356 
Syringe,  Anel,  759 

lacrimal,  introduction  of,  758 
Syrup  of  hydriodic  acid,  354 

Tabes  dorsalis,  optic  nerve  type  of,  534 
Taenia  ecchinococcus  in  vitreous,   458 
solium  in  vitreous,  458 


828 


INDEX 


Takamine's  adrenalin-chlorid,  6o9 
Tangent    method    of    measuring    stra- 
bismus, 600 
Tannin,  195,  200 

and  glycerin,  206,  219,  229,  239,  245 
Tansley-Hunt  operation  for  ptosis.  662 
Tape  method  of  measuring  scpiint,  601 
Tapeto-retinal  degeneration,  515 
Tapeworm  larva;  in  eye,  458,  459 
Tarsadenitis  meiboinica,  1S2 
Tarsal     tumor,     182.     See     Chalazion. 
Tarsitis,  188 
Tarsocheiloplastic  operation,  ^'an  Mil- 

Ungen'.s,  668 
Tarsorrhaphy,  665 

angular,  665,  666 

interrupted,  674 

lateral,  665 

median,  284,  665,  666 
Tarsus,  enchondroma  of,  181 

extirpation  of,  for  trachoma,  689 

hypertrophy  of,  181  1 

inflammation  of,  188  I 

o.ssification  of,  181 

tuberculosis  of,  187 
Tattooing  cornea  in  leukoma,  691 

needle,  692 
Tea  amblyopia,  553 

Tea-leaf  conjunctivitis,  206  ' 

Teale's  method  of  cataract  extraction,    | 
724 

operation    for    symblepharon ,    684, 

685  I 

Tear-tluct,  diseases  of,  625 
Tear-stone,  622  ' 

Teeth,  examination  of,  277 
Telangiectatic  sarcoma  of  choroid,  392 
Telescopic  spectacles  in  myopia,  143 
Temperature  of  ccmjunctival  sac,  50 
Temjjoral  slant,  563 

wall  of  orbit,  resection  of,  720 
Tenderness  of  globe,  328 
Tendons,  shortening  of,  756 
Tenomitis,  390,  635 

after  tenotomy,  749 
Tenon's  capsule,  advanccineiit  of,  756 
fat  implantation  into,   after  enu- 
cleation, 715 
implantation  of  artificial  globe  in, 
after  einicleation,  714 
Tcnotoniv.  747 

coinplefe,  747 

complii'jilions  ;ifter,  719 

Crilchett's  method,  717 

graduated,  749 

in'het.(!rophoria,  (iHi 

in  stral)isnius,  <)()6,  (J07 

of  <'xt((rn;d  n^^t us  iiius<'le  in,  142 

of  inf<(rior  obli(|ue,  748 
indicalidus  for,  748 

<)|)en  method,  747 

partial,  749 

Snellen's  method,  718 

Stevens'  method,  718,  719 

Hulfconjunctivai,  717 

von  (iraefe's  method,  717 


Tension,  intra-ocular,  90 
Tensor  choroidea;,  36 
Teratoid  tumors  of  cornea,  309 
Teratoneuroma  embryonale   of  ciliary 

body, 358 
Terrien's    method    of   implantation   of 

cartilage  after  enucleation,  715 
Tertiary  ulcers  of  eyelids,  179 
Tessellated  fundus,  ill 
Test  types,  35,  67 
DeWecker's,  68 
in  correction  of  hyperopia,  130 

international,  66 
Testing  aeuteness  of  vision,  66 

of  e\e,  functional,  47 
Tetanus,  318 
Tetany  cataract,  437 
Tetranopsia,  568 
Theobromin,  657 
Thermoi)hore,  276 
Thermotherapy,  286 

in  corneal  ulcer,  275 

in  hypopyon  keratitis,  376 
Thiersch's    method    of    skin    grafting, 
679 
in  symblepharon,  684 
Thiosinamin,  25(3,  281 
Third  nerve,  57,  572.     See  also  Oculo- 

molor  nerve. 
Thomas'  stricturotome,  758 
Thompson's    method    of    curettage    in 

dacryocystitis,  758 
Thomson    and   Curtin's   operation   for 
retinal  tletachment,  708 

lantern    test   for   color-blindness,    70 

refractometer,  117 

test  for  color-blindness,  70 
Thorium,  188 
Thrombosis  of  cavernous  sinus,  635 

of  central  vein  of  retina,  505 
Thunil)  exercises  in  heterophoria,  616 
Thyroid   extract,    278,    293,    303,    315, 
355,  368,  456,  489 
amblyopia  from,  539 
Tincture  of  benzoin,  262 

of  iodin,  270,  272,  286 

of  iron,  336,  380 
Tinea  tarsi,  175 
Tobacco  aml)l\()|)ia,  5.39 
Tobacco-poueh  suturt',  712 
Toilds  methotl  of  advancement,  753 
Tolui<lin-blue,  51 
Tonic  cramj)  of  orbicularis,  189 
Tonometers,  90,  397 
Toric  lenses,  30 
Torsion,  573 

inward,  572 

outw:ird,  572 
Torus,  30 
Total  anterior  staphyloma,  211 

iridoplegia,  62 
Toti's  oneration,  761 
Tower  .skuIIs,  525 
Toxic  aml)lyopia,  539,  562 

conjunctivitis,  201,  214 
Toxin  liieory  of  optic  neuritis,  529 


INDEX 


829 


Trachoma,  acute,  230  236 

bacillus  of,  231 

bacteriology'  of,  231 

bodies,  232" 

brossage  in,  240 

causes,  230  ,230 

chronic.  233 

cicatricial,  234,  236 

combined  excision  for,  688 

complications  of,  234,  236 

diagnosis,  237 

diffuse,  234 

distribution,  230 

excision  of  retrotarsal  fold  in,  687 

expression  for,  686 

extirpation  of  tarsus  for,  689 

foUicles,  232 

folHcular,  233   235 

gelatinous,  235 

granulations  of.  232 

grattage  in,  240,  687 

high-frequency  current  in,  240 

Knapp's  operation  for,  686 

Kuhnt's  operation  for,  689 

McMulIen's  operation  for,  687 

medication  in,  241 

mixed,  234 

modified  brossage  for.  687 

non-inflammatory  follicular,  234 

of  lacrimal  sac.  625 

operations  for,  240,  685 

pannus  \\ath,  236 

papillary,  233 

pathology  of.  232 

prognosis,  237 

radium  in,  240 

sclerosing,  234 

sequelae  of,  236 

s%Tnptoms.  235 

treatment,  238 

varieties  of,  232,  233 

with  pannus,  treatment,  240 

x-ray  in,  239 
Trachomatous  conjunctivitis,  229.     See 

also  Trachoma. 
Tragacanth,  239 
Transient  myopia.  328 
Transillumination  of  frontal  sinus,  644 
Transitory  hemianopsia,  561 
Transmission  of  Ught,  17 
Transparent  media,  opacities  in,  103 
Transplantation  for  pterygium,  683 

of    mucous    membrane    in    symble- 
pharon,  684 

operations,  double,  667 
Traumatic  ambh'opia.  506,  549 

anesthesia  of  retina,  506 

choroiditis,  379 

conjunctivitis.  244 

dislocation  of  lacrimal  gland,  621 

iritis,  306,  341 

keratalgia,  305 

keratitis,  303,  306 

miosis,  62 
mydriasis,  346 

perforations  of  macula  lutea,  508 


Traumatic  striped  keratitis,  307 
Traumatisms  of  retina,  506 
Trelhsed  opacity  of  cornea,  298 
Trench  nephritis,  476 
Trephine,  sclerectomy  with,  703 
Trephining,  corneoscleral,  in  glaucoma, 
421,  423 

sclera  for  detachment  of  retina,  708 

scleral,  703 

sclerocorneal,  703 
Trial  lenses  in  correction  of  hyperopia, 

130 
Trichiasis,  176,  192 

double  transplantation  for,  667 

electrolysis  for,  667 

Jaesche-Arlt  operation  for,  667 

operations  for,  666 
Trichloracetic  acid,  262,  272,  286 
Trichophyton  tonsurans  in  eyelashes, 

177 
Trichosis  carunculse,  258 
Trifocal  lenses,  166 
Trikresol,  656 
Triplopia,  binocular,  600 
Trochlear  nerve,  572 
Tropacocain,  656 
Tropometer,  576,  766 

use  of,  766 
True  IjTnphatic  retention  cysts,  309 
Trypanosoma  equiperdum,  294 
Trypanosome  keratitis,  294 
Tscherning's  theory  of  accommodation, 

36 
Tubercle  bacillus,  260.  266 

of  iris,  340 

attenuated,  340 
C9nfluent,  340 
disseminated  miliarv.  340 
TubercuUn,    187.    262.    278,    298,    312, 
315,  341,  354,  368,  379,  380,  482, 
539 

Koch's,  341 

T.  292.  293 

T.R.,  238,  341,  394 
Tuberculosis     of     angle     of     anterior 

chamber  of  eye,  347 

of  choroid,  393 
chronic,  393 

of  ciliary  body,  358 

of  conjunctiva,  255 

of  cornea,  270 

of  evelids,  187 

of  iris,  340 

of  lacrimal  gland,  621 
sac,  625 

of  retina,  482 

of  tarsus,  187 
Tuberculous  choroiditis,  379 

iritis,  340 

keratitis.  270 

meningitis,  393 

scleritis,  313 

ulcer  of  cornea,  270 
Tumors,  lacrimal,  623 

of  anele  of  anterior  chamber, 
347"^ 


830 


INDEX 


Tumors  of  brain.  523 
of  choroid.  388 
of  ciliar\'  body,  357 
of  conjunctiva,  250 
of  cornea,  307 
of  eyelids,  179 
of  iris,  344 
of  lacrimal  gland,  ()21 

sac,  620 
of  optic  nerve,  542 
of  orbit.  636 
removal,  719 

Lagrange  andJ^Knapp^s  method, 
720 
of  sclera,  316 
Turpentine,  oil  of,  308 
Tvloma  conjunctivae,  243 
Tylosis,  176 
Tvpes,  Snellen's,  35 
test,  67 
international,  06 
Tyrosin,  456 

Ulceraxs  mycotica,  209 
Ulcers,  diplobacillary,  200,  270 

of  conjunctiva,  249 

of  cornea,  257,  263.     See  also  Cornea, 
ulcers  of. 

of  eyelid,  postvariolous,  172 

of  sclera,  310 

phlyctenular,  200 

pimple,  204 

rodent,  of  eyelids,  183 

syphilitic,  of  eyelids,  187 

tertiary,  of  eyelids,  179 
Ulcus  internum,  280 

rodens  of  cornea,  268 
Ultex  one  piece  bifocal  lens,  163 
Underlying  conus,  106 
Unequal  pupils,  65 
Unguentum  hydrargyrum,  335 
Unilateral  cataract,  436 
extraction  of,  446 

reflex  blindness,  64 
iridoplegia,  64 
Unit  of  convergence,  44 
Upright    image,     97,     101.     See     also 

Ophlhah/ioscopy,  direct  method. 
Uremic  amaurosis,  551 

amblyopia,  551 
Urticaria  of  eyelids,  170 
Uvea,  congenital  ('(^tropion  of,  320 
Uveal  tract,  (lisea,ses  of,  from  diseases 
of  nasal   acce.s.sory  sinuses,   t)J7 
pseudo-tumors  of,  392 
Uveite  irienne,  337 
Uveitis,  349 

anaphylactic,  359,  305 

anterior,  2S7 

causes,  350 

choroiditis  in,  352 

chronic;,  350 

Descemet's  membrane  in,  353 

dots  on  cornea  in,  i{51 

electric  treatment  in,  355 

fibrinosH  sympathetica,  300 


Uveitis,  galvanism  in,  355 
infective,  360 
iridectomy  in,  355 
malignant,  352 
massage  in,  355 

mutton-fat  deposits  in,  352,  353 
paracentesis  in,  355 
pathology,  353 
proliferative,  364 

punctate  deposits  on  cornea  in,  352 
radium  in,  355 
.sclerotomy  in,  355 
senile,  352 

serous  sympathetic,  360 
sympathetic,  300 
.symptoms,  351 

tapping  anterior  chamber  in,  355 
treatment,  354 

Vaccine,  740 

antistaphylococcic,  740 

blepharitis,  172 

gonococcic,  339 

staphylococcic,  354 

vesicles  on  eyelids,  172 
Valk's    method    of    shortening    ocular 

tendons,  750 
Van  der  Hoeve's  scotoma,  649 
Van  Lint  flap,  738 

Van  Millingen's  tarsocheiloplastic  opera- 
tion, 008 
Variolar  abscess  of  cornea,  267 
Vasehn,   172,   177,   178,   183,  215,  224, 
229,  257.  305,  679 

bichlorid,  305,  008.  727,  732 
Vascular  keratitis,  287 
Vascularization  of  cornea,  287 
Vasculitis,  497 
Vasomotor  blepharitis,  175 

dilatation  of  vessels,  312 
Vegetable  oils,  240 

Venesection  in  vitreous  opacities,  454 
Verhoeff's    operation    for    retinal    de- 
tachment, 708 
Vernal  conjunctivitis,  225 
Verruca  on  eyelids,  179 
Verrucosities  of  choroid,  382 
Vertical  hemianopsia,  500 

meridian,  32,  573 
strabismus,  008 
Verlicillium  graphii,  20t> 
\ertigo    in    paralytic    strabismus,    581 
Wsicular  grainilations,  235 
\'estii)ular  nystagmus,  OlS 
\  ibration  nijvssjige  of  cornea,  2S1 
N'ieniia    method    of    enucleation,     709 
N'iolel  blindness,  70.  547 

in  nlliumiiniric  retinitis.  474 
Virtual  focus  of  convex  lens,  21 

image  of  convex  lens.  27 
Vision.  17 

acutene.><s  of,  in  myopia,  144 
testing,  0(> 

binocul.'ir.  574 
single,  575 

loss  of,  in  s(iuint,  5S() 


\\ 


INDEX 


831 


Vision,  blue,  560 
color,  theor}'  of.  547 
color-field  of.  86 
dimness  of,  545 
direct,  81 

for  colors,  72 
distortion  of,  in  retinitis,  465 
disturbance  of,  328 
field  of,  81.     See  also  Field  of  vision. 
green.  560 

halo,  in  glaucoma,  405 
in     obstruction     of     central    retinal 

artery,  502 
in  optic  neuritis.  520 
in  shell-shock,  550 
indirect,  81 

inequahty   of,   in   concomitant  stra- 
bismus, 598 
iridescent,  560 

in  glaucoma,  405 
loss  of,  545 
monochromatic,  70 
obscurity  of,  545 
of    periphery    of    retina,    acuity    of, 

88 
red,  660 

second,  135,  429 

test  for  acuteness  in  peripheral  part 
•  of  retina,  88 
testing  acuteness  of,  66 
Visual  acuteness,  35 

in  cataract,  429 

in  retinitis,  465 

normal,  35 
angle,  34 
axis,  41 
cells,  564 

field.     See  Field  of  insion. 
line,  41 

rotation  of  eyeball  around,  573 
phenomena  in  pituitarv  bodv  disease, 

562 
radiations,  566 
tract,  564 
zone,  122 
Vitreous,   abscess  of,  385,  451 
air  bubbles  in,  319 
blood-vessel  formation  in,  457 
cholesterin  in,  456 
coloboma  of,  459 
cysticercus  cellulosse  in,  458 
detachment  of,  459 
diseases  of,  451 
entozoa  in,  458 
examination  of,  bv  transmitted  light, 

103 
exudation  into,  331 
fatty  degeneration  of,'  454 
filaria  sanguinis  hominis  in,  459 
fluidity  of,  456 
foreign  bodies  in,  320,  457 
hemorrhage  into,  455 

malignant,  456 

recurrent,  456 

spontaneous,  455 

treatment,  456 


Vitreous  opacities,  374,  452,  466 
causes,  453 
detection  of,  452 
dust-hke,  453 
fixed,  452 
from  diseases  of  eye,  453 

of  nasal  accessory  sinuses,  647 
from  injuries  of  eye,  453 
from  refractive  error,  453 
from  systemic  disease,  453 
inflammatory,  453 
method  of  detection,  452 
morning,  452 
prognosis,  454 
snow-baU,  453 
symptoms,  452 
treatment,  454 
without  apparent  cause,  453 
persistent  hyaloid  artery  in,  459 
pus  in,  451 

svmptoms,  451 
treatment,  452 
taenia  ecchinococcus  in,  458 
sohum  in,  458 
Von  Graefe's  equilibrium  test,  75 
method    of    extraction    with    iridec- 
tomy, 726 
of  tenotomy,  747 
sign  in  exophthalmic  goiter,  642 
Von  Helmholtz  ophthalmoscope,  95 
von  Hippel's  disease,  501 
Vossius'  ring,  441 
V-shaped  iridotomy,  698 

Wainscoted   fundus   in   retinitis    pig- 
mentosa, 484 
Wallace's  astigmatic  chart,  153 
Wall-chamber  cysts,  344 
Warts  on  eyeUds,  179 
Wassermann  serum  reaction,  179,  291, 
332 

test,  628 

in  atrophy  of  optic  nerve,  535 
Weak  eyes,  175 
Weber's  canaUculus  knife,  757 
Wedge-isolation  operation  of  Herbert, 

702 
Weeks'  bacillus,  202 

method  of  restoring  culdesac,  681 
Wernicke's  fibers,  566 

symptom  in  hemianopsia,  571 
Westphal-Piltz  reaction,  57 
West's  operation,  761 

window  resection   of  nasal   duct  in 
stenosis,    761 
Wheel-rotation,  573 
White's  ointment,  732 
Whole   boiled  milk  in  eye  infections, 

277 
Widmark's  conjunctivitis,  249 
Width  of  cornea,  51 
Wiener's  method  of  advancement,  753 

operation  to  enlarge  contracted  sock- 
et, 681 
Wildbrand's  hand  perimeter,  85 
Wilder's  double  knife,  670 


832 


INDEX 


Wilder's  operation  for  ptosis,  664 
Window    resection    of    nasal    duct    in 

stenosis,    761 
Wire  loop,  728 

Wolff's  operation  for  ptosis,  661 
Wolffberg's  test,  67 

Wood    alcohol,    am})lvopia    from,    554 
Woolly  choroid,  372    " 
Word-blindness,  congenital,  548 
Worth's  amblyoscope.  604 

method  of  advancement,  753 

operation  for  ptosis,  (Itil 
Worth-Black  amblyoscope,  605 
Wounds  of  conjunctiva,  257 

of  cornea,  305 

of  eyelids,  196 
Wiirdemann  transilluminator,  56 

Xanthelasma  of  eyelids,  181 

Xanthoma  of  eyelids,  181 

Xeroderma    pigmentosum    of    evelids, 

188 
Xeroform,    276 
Xerophthalmos,    247 
Xerosis,  236,  247 

bacillus,  200,  202,  223,  247 

of  conjunctiva  with  infantile  ulcera- 
tion of  cornea,  282 
Xerotic  keratosis,  282 
x-Rays,   171,  228,  256,  536,  637,  638 

conjunctivitis  from,  244,  560 

for  carcinoma  of  eyelids,  186 

in    diagnosis    of    atrophy    of    optic 
nerve,  535 

in  glioma,  512 

in  trachoma,  239 

in  uveitis,  355 


z-Rays,   localization   of   fc^reign  bodies 
with,  320,  450,  768 

Yeast  serum,  275 

Yellow  halo  in  glaucoma,  398 

oxid  of  mercury,  177,  221,  225,  227, 
239,  249,  261,  271,  281,  294,  295, 
296,305,312 

spot,    108.     See    also    Macula   lulea. 
Yellow-blue  blindness,  547 
Yohimbin.  658 
Young-Helmholtz  theorv  of  color  vision, 

547 

Zeiss  binocular  magnifier,  52 

corneal  microscope,  52 

glands,  171 
Ziegler's  iridotomy.  698 

keratectomy  for  staphyloma,  691 

method  of  advancement  of  Tenon's 
capsule,  756 
of  introduction  of  lacrimal  probe, 
757 

operation     for     after-cataract,  •  745 

partial  tenotomv,  750 
Zinc,  200,  207,  270 

chlorid,  243 

ions  in  Mooren's  ulcer,  277 

iontophoresis  for  purulent  keratitis, 
276 

oxid,  174,  177 

sulphate,  178.  205,  243 
Zone,  circumcorneal,  49 

of  zinn,  coloboma  of,  427 

visual,  122 
Zonular  opacity  of  cornea,  300 
Zorab's  operation,  706 


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LT)  21-50m  8,"57                                      University  of  Culifornia 
(C8481sl0)476                                                    Berkeley 

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